Nancy Posted Thu 20th of May, 2010 17:09:55 PM
One of my doctors in our Rheumatology dept was called into the infusion lab because a patient wa having a reaction to a drug that was being infused and treatment was given and then the patient was sent to the ED.The doctor wants to know if she can bill this as a E/M. She has few lines of documentation. Can she do this? Thanks
SuperCoder Answered Fri 21st of May, 2010 11:30:04 AM
Yes, you can bill this separately only if the patient is not subsequently admitted as inpatient by the ED physician.
Nancy Posted Mon 24th of May, 2010 14:30:34 PM
Thank You for your response. The patient was not admitted but the dictation reads HPI 10 am. Pt with hives today during Remicade infusion. it was stopped. No chest pain or dyspnea. No throat swelling. BP-124/80. CV-RRR. Lungs-CTAB. Will monitor in infusion suite. Given 120 mg Solu-medrol and 50 mg Benadryl.
At 1 pm pt complained of chest tightness and polyarthralgias. lungs were clear & vitals stable. Given 0.3 mg IM epinephrine with no response, paramedics came and pt sent to the hospital. The doctor wants to bill a level 5. Would this be appropriate? Thanks again
SuperCoder Answered Tue 25th of May, 2010 07:09:10 AM
Level 5 is okay. You could bill for the injections (96372 x 2 & 96373) with a modifier 25 to the E/M. I hope 'sent to the hospital' refers to the patient sent back to the ED and not admitted as inpatient.