Pulmonology Coding Alert

Question: Our pulmonologist put one of our established patients on a new drug regime. The patient visited our office for her next appointment after a period of three weeks. During this visit, our non-physician practitioner examined the patient and recorded the vitals and checked with the patient about any adverse effects after beginning the drug prescribed. The documentation of the visit mentions that the patient was only evaluated to check about the medication being taken, and no side effects were noted. How should I report this visit?

Maryland Subscriber

Answer: Since your non-physician practitioner (NPP) evaluated and assessed the patient during the visit, you can report the visit using the E/M code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem[s] and the patient's and/or family's needs. Usually, the presenting problem[s] are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family). You will need to provide adequate documentation to show that the patient evaluation was provided by the NPP.

Along with the E/M code, you will also need to report the diagnosis code (using the appropriate ICD-9 code) for which the medication was prescribed in the initial visit. If the documentation recorded any side effects that the patient was experiencing after taking the medication, these also should be reported along with the E/M and the diagnosis code.

If instead of your NPP, any other qualified clinical staff like your RN provides the care during the visit under guidance from your pulmonologist or your NPP, then you will have to report the visit using 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). However, the diagnosis and the codes for the side effects recorded in the documentation should still accompany the E/M code.

Note: A higher E/M visit can be reported if the patient is experiencing any kind of complications after beginning on the new drug regime. So, instead of 99212, you might have to report the E/M with 99213-99215 (Office or other outpatient visit for the evaluation and management of an established patient...) depending on the level of evaluation the patient needs during the office visit.