Pulmonology Coding Alert

Question: I always have trouble coding evaluation and management (E/M) visits. Recently, an established patient who has moderate persistent asthma with acute exacerbations presented for a follow-up appointment to assess their condition. The pulmonologist did a physical exam, performed spirometry, and interpreted the results. The physician then adjusted the patient’s long-acting beta agonists (LABA) prescription.

Could you tell me what E/M code to assign for this visit?

Ohio Subscriber

Answer: You’ll assign 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter.) to report this E/M encounter.

The E/M guidelines feature a handy table that helps you determine the level of medical decision making (MDM) to find the correct E/M code. The table features three elements of MDM, but the medical documentation needs to support two of the three elements for that level of MDM.

The elements of MDM include:

• Number and complexity of problems addressed at the encounter
• Amount and/or complexity of data to be reviewed and analyzed
• Risk of complications and/or morbidity or mortality of patient management

In your case, the patient has a chronic illness with exacerbation (moderate level), and your provider performed prescription drug management (moderate level). Since your case meets two of three elements for a moderate level of MDM, and the physician saw an established patient, you can correctly assign 99214 for the encounter. You cannot count the physician order and reviewed the results of spirometry towards data since the pulmonologist will be separately billing for the spirometry.