Office visit & nebulizer treatment
What codes should I submit if, during a problem-oriented office visit, I decide the patient requires a nebulizer treatment and the nurse gives the patient instructions on using a nebulizer or metered dose inhaler at home?
You should submit the appropriate evaluation and management (E/M) office visit code, the code for the nebulizer treatment (94640, “Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes (e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device)”), the code for the nurse’s instructions (94664, “Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device”) and the correct J code for the supply of the nebulizer drug. You should also add modifier -25 to the E/M code to indicate that it was a significant, separately identifiable service from the other services described.
Admissions on separate dates
In our small town, the admitting physician often also sees the patient in the ED. If a patient is seen in the ED at 11 p.m. and is not seen as an inpatient until after midnight, should the physician submit two separate E/M codes since the services were provided on different dates?
Yes. CPT states that “all [E/M] services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission” (emphasis added). In the situation you describe, the ED visit and the initial hospital care occurred on different dates and should be billed separately, since the initial hospital care (“the first hospital inpatient encounter with the patient by the admitting physician”) did not occur until after midnight. The Medicare Carriers Manual provides similar advice.
Coding a discharge summary
In our group, one on-call physician covers call and hospital rounds for the weekend. This physician handles any hospital discharges, submitting the appropriate hospital discharge code (99238 or 99239). The attending physician dictates the discharge summary at a later date since the attending is more familiar with the entire hospitalization. Recently, however, we have been told that the on-call physician must dictate the discharge summary before he or she can submit 99238 or 99239. Is this true?
No. The hospital discharge process you describe is consistent with CPT as long as both physicians don’t submit the hospital discharge code for the same patient and the attending physician does not bill a separate E/M service for dictating the discharge summary. According to CPT, codes 99238 and 99239 include, as appropriate, final examination of the patient, discussion of the hospital stay, instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms. CPT also states that these codes are to be used by the physician to report all services provided to a patient on the date of discharge (if that date differs from the initial date of inpatient status). Your group has decided it is appropriate for the attending physician to dictate the discharge summary and for the on-call physician to code 99238 or 99239 for all of the services he or she provided on the date of discharge.Medicare and many other payers often treat physicians of the same specialty in the same group practice as a single physician, so the fact that the work of 99238 or 99239 is split between the on-call and attending physician is not problematic.
Editor’s note: While this department attempts to provide accurate information and useful advice, third-party payers may not accept the coding and documentation recommended. You should refer to the current CPT and ICD-9 manuals and the Documentation Guidelines for Evaluation and Management Services for the most detailed and up-to-date information.
