Question: After a patient receives an allergy injection, she has an anaphylactic reaction to the injection. The otolaryngologist starts an IV to deliver fluids and 4 mg of dexamethasone. In addition, he administers 3 cc of epinephrine twice and 25 mg of Benadryl intramuscularly. The patient also requires oxygen. The physician spends another 30 minutes directly observing the patient. How should I code the treatments in the office and his time?
Answer: You should report each service separately, starting with the original encounter the allergy injection. Code the injection with the appropriate injection code, such as 95120 (Professional services for allergen immunotherapy in prescribing physician's office or institution, including provision of allergenic extract; single injection). Services such as nurse observation do not warrant billing a separate E/M. As CPT states, "Codes 95115-95199 include the professional services necessary for allergen immunotherapy."
However, a patient who has a severe reaction requires a physician's services. Therefore, you should report the appropriate established patient office visit code (99211-99215). The incident's seriousness and potential for morbidity probably involve a moderate to high level of medical decision-making and may justify billing 99214-99215. To indicate that the service constitutes a separate service, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code.
If the otolaryngologist spends more than 30 minutes over the time CPT allots for the E/M code, you should report prolonged services. For instance, if your doctor indicates he performed a 99215 ( physicians typically spend 40 minutes) and remained with the patient for an additional 30 minutes, use +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]). For each additional 30 minutes, assign +99355 ( each additional 30 minutes [list separately in addition to code for prolonged physician service]). Although you did not indicate how much initial time your doctor spent with the patient, to bill +99354 your doctor must have documented 70 minutes of total face-to-face time.
Note: Many physicians overlook charging prolonged services, which reimburse in excess of $100. However, thorough documentation is required to capture this opportunity.
For the IV infusion, assign 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) for the administration of the dexamethasone and fluids. If the IV infusion continued longer than one hour, [...]