A pediatric patient with a history of asthma and pneumonia presented to the office with severe respiratory distress. The pediatrician performed a detailed history and comprehensive examination, and diagnosed the patient with status asthmaticus. A pulse oxygen level was taken and it was determined that the patient’s blood oxygen level was at 88%. The patient was started on a nebulizer treatment at 0950 hours, which lasted until 1015 hours. The physician then re-checked the patient and determined that the patient’s breathing had only slightly improved. A pulse oxygen level was taken again and it was determined that the patient was at 92%. The physician then ordered another nebulizer treatment, which was started at 1032 and continued until 1054. After this second breathing treatment, an additional pulse oxygen level was taken and the patient’s blood oxygen level had risen to 97%. The pediatrician then determined that the patient needed to be sent for chest x-rays to determine whether or not pneumonia was present in the lungs. Due to the resulting amount of data and risk, the pediatrician considered the MDM of high complexity. The total time spent with the patient was 1 hour 45 minutes.
What E&M codes would you use to code for the office visit?
Explanation
Answer: D - You would report this office visit with the E&M codes: 99215 (Established Patient Office Visit, Level Five), and 99354 and 99355 (X2) (Prolonged Services). Code 99215 is established by the detailed history, comprehensive examination, and the MDM of high complexity. The appropriate prolonged services codes are: 99354 (First 30-74 minutes Over), which represents the time spent beyond what is allowed for the 99215 code and the 99355 (X2) (Rest of the Time Spent with the Patient), which in this case is a total of 1 hour and 45 minutes. If the physician spent 1 hour and 44 minutes, then the correct number of units for 99355 would be 1, but that is not the case.
