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Q.I am using an EHR, but it does not seem to code nebulizer treatments correctly. It produces codes 94640 (nebulizer treatment) and J7620 (albuterol/ipra – tropium bromide), but it misses the codes for administration set, with small volume non-filtered pneumatic nebulizer, disposable (A7003) and tubing (A7011 ). Why is this?

A.The administration set code (A7003) and tubing code (A7011) code are actually bundled into the code for the treatment (ie, they are included in 94640). Thus, it is not appropriate to add these codes when your clinic performs nebulizer treatments.

Q.What HCPCS code should my clinic use for diltiazem IV?

A.Unfortunately, there is no HCPCS code for IV diltiazem. You will have to eat the cost.

Q.Our doctor personally checks each pediatric patient before giving the influenza vaccine, so we would like to know if we can add an E/M code to the visit and if a copay can be collected?

A.As far as adding an E/M code to a visit for a vaccination, this would depend on the visit. For most routine patient visits that are just to administer an influenza vaccination, a separate E/M would not be medically necessary.

If there is medical necessity for additional evaluation and management and the physician documents the history, physical, assessment, and plan, then it would be appropriate to document the additional information and code the E/M based on the evaluation and management. Thus, for a patient presenting for a DTaP, who had suffered a significant reaction to a previous DTaP or was suffering a concurrent respiratory infection, then it might be appropriate for the physician to perform a direct evaluation and management of the patient.

If the physician provides counseling related to the vaccination, the procedure should be coded with 90460—Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component. Since the code specifically includes counseling related to the vaccination, you should not add an E/M for just adding counseling to the visit for a child through 18 years of age.

If the patient receives an annual wellness exam during the same visit, it would be appropriate to choose the proper code (99391-99397) based on the age of the patient (eg, 99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]).

Q.How would you code an urgent care visit for chest pain with hypertension for nitroglycerine monitoring with serial VS monitoring, ECGs, and stabilization of the patient?

A.You would usually code either:

  • E/M (99205 or 99215: new patient, physician office visit). Make sure that you provide proper documentation to support this code.
  • Critical care (99291—Critical care, evaluation and management of the critically ill or critically injured patient, first 30-74 minutes). You may use this higher-paying code outside of a hospital in an urgent care, but you must follow CPT guidelines for reporting critical care services. The two key points of the CPT definition of critical care are:
  • The patient must be suffering a critical illness or injury as defined by CPT: an illness or injury that “acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient’s condition.”
  • In critical care, the physician treats single or multiple vital organ system failure(s) and/or prevents further life-threatening deterioration of the patient’s condition, and the physician must continue these life-sustaining services for at least 30 minutes.

Although the physician does not usually provide these services in an urgent care center for an extended time, the physician may perform them until the patient can be transported to a hospital. In general, critical care codes are easier to document than other E/M services, as you must simply note the reason for the critical care, the time spent, the specific care given.

Note: CPT codes, descriptions, and other data only are copyright 2011, American Medical Association. All Rights Reserved (or such other date of publication of CPT). CPT is a trademark of the American Medical Association (AMA).

Disclaimer: JUCM and the author provide this information for educational purposes only. The reader should not make any application of this information without consulting with the particular payors in question and/or obtaining appropriate legal advice.

DAVID STERN, MD (Practice Velocity)

Nebulizer Supplies, Diltiazem IV, Influenza Vaccines with E/M Codes, and Critical Care Coding in Urgent Care

David Stern, MD

Chief Executive Officer at Experity, Previous Chief Executive Offer at Practice Velocity Urgent Care Solutions, Founding Member of the Urgent Care Association of America, Publishing Staff for The Journal of Urgent Care Medicine