Q&A: How to code an emergency in a physician office

Q: Recently, a patient in our rural practice came in with symptoms of slight nausea, lightheadedness, and a headache. Our physician examined the patient, found his blood pressure, temperature, etc., to be normal, and performed an ECG. Some tachycardia was noted in the tracing. Our physician conferred with the patient's cardiologist, and it was decided to admit him to the hospital.

When the patient was examined, no definitive diagnosis was established other than the mild tachycardia and two chronic conditions-diabetes mellitus and mild COPD.

On the way out of the office, the patient suffered heart failure. We called 911 while our physician resuscitated the patient. Since we are in a rural community, the response time can be longer than in a metropolitan area. All totaled, our physician was constantly with the patient for about 45 minutes. Our physician left the office, followed the squad to the hospital, and oversaw the patient's admission to the intensive care unit. She stayed with the patient until the on-call cardiologist arrived.

A: We will walk through the coding process based on the information you have provided. There may be more specific information in the patient's record, so take that into consideration when choosing codes to submit your claim.

PROCEDURE (CPT) CODES

99213, 99214, 99215: Office visit level depends on the documented services provided and the patient's symptoms; place of service: 11–office. Attach modifier –25 to the E/M service chosen. 93000: ECG-12 lead; place of service: 11–office.

DIAGNOSIS (ICD-9-CM) CODES We are coding symptoms, since no definitive diagnosis seems apparent: 787.02 (generalized nausea), 780.2 (syncope), 784.0 (headache), 794.31 (abnormal ECG-you did not indicate the type of tachycardia), 250 (diabetes mellitus-fill in the rest), 496 (COPD-NOS).

PROCEDURE (CPT) CODES

99058: Services provided on an emergency basis in the office, during regularly scheduled hours disrupting other scheduled services; place of service: 11–office (most insurers historically do not pay this code separately). 92950: CPR; place of service: 11–office. 99291 X 1: Critical care 30-74 minutes. If the chart documentation shows attendance for more than 74 minutes, then critical care 74-104 minutes is appropriate; place of service: 11–office. 99223: Hospital admission care (comprehensive medical decision making) is bundled with any other E/M service on the same date and cannot be billed separately if an office service is billed; place of service: 21–inpatient hospital. (The provider does have the option of charging for initial hospital care and not charging for the office call; grouping all the services provided in both E/M services together to choose the level of care, which would be recommended since inpatient admission care normally reimburses at a higher rate than EP office services.) 99292X 2: Critical care each additional 30 minutes-the additional hour of critical care provided in the hospital upon admission; place of service: 21-inpatient hospital. 31500: Insertion of endotracheal tube is included in critical care and cannot be billed separately.

DIAGNOSIS (ICD-9-CM) CODES

429.41 (acute combined systolic and diastolic heart failure), 584.9 (acute renal failure, unspecified-use this diagnosis for the time prior to the nephrology consult), 250 (diabetes mellitus, fill in the rest), 496 (COPD-NOS).

It is important for the provider and coder to know which procedures are bundled together, which procedures are independent, and how to code for diagnoses that are only symptoms when the patient is first seen, even though a more definitive diagnosis may be made when the patient is evaluated with further testing. In addition, they must know which diagnosis codes affect medical necessity for individual procedures, by insurer. You will probably need to send this claim for review.

The author, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant. She is also a certified coding specialist, certified compliance officer, and a certified medical assistant.