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 physician assistant (PA) 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 PA evaluated and assessed the patient during the visit, you can report the visit based on the extent of the documentation, likely using an E/M code such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient…). You will need to provide adequate documentation to show that the patient evaluation was provided by the PA.

Along with the E/M code, you will also need to report the diagnosis code (using the appropriate ICD-10 code) for which the medication was prescribed in the initial visit. If the documentation noted 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 PA, any other qualified clinical staff like your registered nurse (RN) provides the care during the visit under guidance from your pulmonologist or your PA, 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…). However, the diagnosis and the codes for the side effects recorded in the documentation should still accompany the E/M code.