Vangie Posted Tue 24th of May, 2011 20:47:32 PM
DX: Nausea and vomiting.
On arrival patient was given D5 LR with Zofran 4 mg IV X 1. At 9:30 IV started 22 gauge, left forearm. D5LR infusing well. Pt denies pain.
9:40 patient resting, denies pain, no problems
10:00. Patient resting.
10:30: D5 LR 1000 ml new bag ung. No complaints.
11:00 IV discontinues. No signs or symptoms of infection at insertion. No redness, swelling pain.
8 mg Zofran, D5 LR in 50 mg NS Start time 09:30 End time 0935
1. 1000 mL D5 LR
2. 8 mg Zofran in 50 mL of NS.
3. 1000 ml of D5 LR.
Preganncy is complicated by diabetes mellitus Type 2. Diabetes was addressed, increased insulin. 24 hour urine collection for 24 hour urine protein and creatinine clearnace elevated. Patient's history is also significant for hypertension, she is on labetalol. Her blood pressures have remained stable since her initial prenatal visit.
Can I assign a E/M since the ddiabetes and hypertension was addressed.
99212/25 (diabetes and hypertension)
99365, intravenous infusion (Zofran). In the notes. zofran was given within 5 minutes (09:30 to 09:35)for (nausea and vomiting).
Would this be considered IV infusion, prophlylaxis or IV push, single per day. I picked up the CPT code 99365???
Is the coding correct?
SuperCoder Answered Wed 25th of May, 2011 00:25:59 AM
The patient is pregnant, complicated with diabetes (now managed with insulin increase) and significant personal history of hypertension(on medication)although stable bp at present, 24-hr urine protein and creatinine elevated. The treatment options taken for her nausea and vomiting symptoms along with other treatment options.
This raises level to 99213 at least. Check with other E/M count in the other parts of the report to justify too.
I would go with 99213-25 and 96365. We can use 96365 as this include even 15 min or less duration. But, to use 96361, I would prefer if the total duration of infusion is 1 hour more than the duration of drug infused. Please check if the calculation goes that way, then you can use 96361 in addition too.