Pulmonology Coding Alert

Question: Our pulmonologist just saw a 13-year-old female patient who had recently been to a local hospital's emergency department (ED) for breathing difficulties associated with her asthma. During the visit, which lasted about 25 minutes, our provider administered the Asthma Control Test to show the patient that the ED admission was due to her inconsistent use of medication. After the test, the provider had the patient see one of our nurses who has been certified by the National Asthma Educator Certification Board. The nurse spent about half an hour on the education session with the patient. What is the best way to code this scenario?

Codify Subscriber

Answer: First of all, you should code for the evaluation and management (E/M) service provided to your patient. You don't say how much of the 25 minutes your provider spent face-to-face with the patient, but if at least half of that time (13 minutes or longer) was spent counseling the patient and managing her condition, the visit should qualify for 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... Typically, 25 minutes are spent face-to-face with the patient and/or family) as long as the time spent counseling the patient, the total time spent, and a note of what was discussed is documented in the medical record. The counseling time can only be reported by the billing provider for his/her personal time, and not for counseling performed by other staff "incident-to" the physician's service.

Next, the Asthma Control Test (https://www.asthma.com/additional-resources/asthma-control-test.html) qualifies as a health-risk assessment tool, which would enable you to code for 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument). (As a side note, this particular tool is appropriate for patients like yours who are over 12-years-old. Younger patients between the ages of 4 and 11 should take the Childhood Asthma Control Test instead.)

Ensure that the nurse's subsequent education session with the patient meets the criteria for 98960 (Education and training for patient self-management by a qualified, nonphysician health care professional using a standardized curriculum, face-to-face with the patient (could include caregiver/family) each 30 minutes; individual patient) in several ways.

By virtue of her certification, your nurse certainly meets the definition of a qualified, nonphysician health care professional, and the length of the session also meets the time requirement of the code. The intent of the session is to train the patient (and caregiver, when applicable) how to self-manage their disease or delay disease comorbidity. Before using 98960, however, you should check with your payer to see if the curriculum provided by your nurse meets their definition of "standardized."

Finally, all this should be linked to an asthma diagnosis code. As you don't give any more details regarding the severity of the patient's condition, you will have to consult your patient's records and your provider before choosing a specific code from the J45.- (Asthma) ICD-10 codes. Be sure to check with payers for coverage since 98960 may be considered to have a "bundled" status (bundled into any other service provided), and 96160 may be excluded from coverage, thereby causing a patient bill.