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5 hour visit

Nancy Posted Wed 19th of May, 2010 18:54:38 PM

Our office had a patient come in with chief complaint of 1 day weakness/dehydration/hyperglycemia with mild hand/foot spasms & fatigue. The visit ended up being 5 hours for ongoing medical care and treatment, stabilization, IV fluids, glucose control, patient education, disease management & coordination of care because the patient refused ER evaluation and hospital admission. The physician wants to bill an acute care cpt code but I disagree because the entire visit was not face-to-face with the patient. I think this should be billed with the E/M code of 99215-25 96360 x 1 and 96361. The IV was started at 12:00 and at 1:30 the 2nd bag was started at 3:00 pt went to bathroom and came back and had infiltrated the IV site Could not insert new IV and the 2nd bag was almost complete. pt d/c at 4:00. Please help and as always Thank You in advance.

SuperCoder Answered Thu 20th of May, 2010 07:11:25 AM

Coding an acute care or critical care CPT code depends on whether the patient's condition was really "critical" (high probability of imminent or life-threatning deterioration) from medical point of view. Failure of any of vital organ system, application of advanced technology etc. are a few of indications of patient's critical condition. Usually CC is provided at a particular CC area, but that may not be a case always. Most importantly, in case a physician provides a CC service to a patient for a long time, the mention of Critical Care service and its reasons and the total time spent providing the critical service in the documentation is mandatory. As far as the time is concerned, it is not always necessary to provide continuous F2F service to the patient. The total time spent on providing CC service is to be counted, even if it happens to be non-continuous. But for any given period of time spent providing CC service, the physician must devote full attention to that particular patient only (may or may not be F2F, time spent on the floor, not at immediate bedside, discussing that patient's Tx & management with fellow doctors, patient's family is still calculable) and not to the Tx management of any other patient.

Therefore the documentation of the service provide throughout the entire 5 hours holds the key to decide whether really this can be coded as an acute care or a CC service (99291, 99292) or should it be coded as E/M service only (99215, as you stated). In any case, modifier 25 is to be added to that code and separate CPT is to be coded for IV infusion. As per the documentation, the IV started at 12.00 and went on till 3.00 when the Pt. went to bathroom and after returning the IV was not given anymore because the 2nd bag was done almost. It seems that between 3.00 and 4.00 o'clock, no more IV was given. In that case, the IV codes should be as follows -- 96360, 96361 X 2.

Guri Answered Sun 08th of August, 2010 18:27:56 PM

Great insight above. I have never been able to figure these situations out. My scenario is more often like this:
A middle aged man has HTN, Diabetes Mellitus type II, COPD, GERD, Obesity, Hyperlipidemia, and Degenerative Disc Disease of the whole spine with chronic incapacitating pain in his back - mostly in the lower back, with radiation of the pain as well as tingling and burning sensations in his feet.

He has gone through 2 separate surgical procedures for his spine separated by 3 years. He does not like how pain medications (NSAIDs, Cox-2 inhibitors, opioids, tramadol, lyrica etc.) make him lose his alertness to varying degrees when he is given enough to decrease the pain level to 'tolerable'.

So, he comes to me about 3 times a month, usually in severe pain, unable to find a tolerable posture, let alone any kind of relief in the pain that he scales at 8-10/10.

I examine him thoroughly - looking for his overall health status with respect to nutrition and hydration, side effects of his medications, complications from his systemic illnesses, the level of his discomfort, the state of his weight, blood pressure, lipids, Skin, bladder, CNS, Psych, and, of course, the muskuloskeletal system. I put him on a lumbar traction device, start him on 250 ml of saline with the following added to the bag: Ketorolac 60 mg, Orphenadrine 60 mg, Infusible Multivitamins, and Magnesium Sulfate 12 mEq.

While the intravenous infusion is going, and after the traction session is finished (usually 20 minutes), the patient continues to be monitored with vital signs every 15 minutes, and a brief examination of the mentation and pain level plus mobility every 20 minutes.

This patient ends up spending almost 180-200 minutes in the office: the first 30 minutes or so going over the CC/HOPI, Medication Reconciliation, 14-point ROS, physical examination, review of tests and X-Rays at times, and then discussions with the patient and his wife about the recommended plan of care.
The rest of the time is spent in delivering the treatments and monitoring the patient.

This patient has been very compliant, never asking for more meds or higher dosages, only occasionally ending up in the ER: perhaps once every 10 weeks or so, usually when his pain gets unbearable before his scheduled appointment with me and the schedule is just impossible for us to fit in a 3hour appointment. This is in contrast to previous fortnightly visits to the ER.

What is the best way to code situations like this? It would become essential for us to do this right because I am starting to see more such situations in my office, usually related to pain management. But sometimes intravenous fluids fir dehydration and / or IVPB for antibiotics, Nebulizer treatments, wound care, and sometimes just counseling and coordination of care, for instance the end of life issues, or comprehensive dietary education involving reviews of diet diaries, and other such patient-education matters.

So, a clearer understanding of the various types of prolonged visit scenarios will be immensely helpful.

Thanks in advance,
Just another old-fashioned family doc.

SuperCoder Answered Tue 10th of August, 2010 21:35:00 PM

A no. of codes can be billed in these kind of scenarios. But there is no constant set of codes. Coding here depends upon case-by-case basis and based upon types of service provided / severity of conditions etc.

As far as this case in concerned, from the above documentation, I do not see any organ / system failure and even no hint of "life-threatening conditions". Therefore Critical care (CC) codes are not the choice of CPT here. As this patient is obviously established to your office, you can code a CPT from the range (99212-99215), based on your documentation. Level of E/M is dependant upon the doucmentation. Add modifier 25 to the E/M code. [I would go with code 99214]. Also, add prolonged services E/M codes (+99354 - +99355) based on the additional time spent. [for e.g. - if total time spent is 200 min. and if primary E/M code is 99215, then codes would be --> 99215, 99354, 99355 x 3]. But please remember, prolonged time must be calculated for the time spent FACE-TO-FACE with the pt. or family. Sustract the time you were not personally providing necessary face-to-face services during the office visit.

IV Infusion: As drugs are being infused with the IV, the code of choice would be 96365 for first 1 hr. of infusion. Add code +96366 for each additional hour of infusion (for infusion intervals of greater than 30 min. beyond 1 hour increments).

Traction: 97012 can be billed. [These codes may be separately reported if, and only if, the patient's condition requires significant, separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure performed.) Therefore, please document the specific reason for performing the traction service, apart from providing other Tx. But this code is intended to be used only once during an encounter, regardless of the number of areas treated.

SuperCoder Answered Tue 10th of August, 2010 21:53:25 PM

Apart from these, to identify the substances that is being infused, code 99070 or the appropriate HCPCS Level II code should be reported for each substance / drug.

SuperCoder Answered Wed 11th of August, 2010 00:30:19 AM

Moreover, you can only use prolonged services for time the physician spent face to face with the patient, not the time the patient was in the office.

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