Health Information Management

Q&A: Coding for an encounter during which a patient stops breathing in the physician’s office

JustCoding News: Outpatient, July 14, 2010

Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

QUESTION: I need help coding for an emergency care visit that occurred in the office. A patient stopped breathing in the office, and with resuscitative efforts we were able to revive him. During this time, we maintained an airway, added oxygen, started an IV, and performed cardiac monitoring. We spent approximately 30 minutes with the patient before the ambulance took him away. Can I report an evaluation and management (E/M) code for this encounter?

ANSWER: From the limited details you provided, an E/M code would not be appropriate because no separate and specific evaluation and/or management services were provided above that which is already included in the code for performing the cardiopulmonary resuscitation (CPR). I would recommend reporting CPT® code 92950 for the CPR (e.g., in cardiac arrest).

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



Want to receive articles like this one in your inbox? Subscribe to JustCoding News: Outpatient!

    Briefings on APCs
  • Briefings on APCs

    Worried about the complexities of the new rules under OPPS and APCs? Briefings on APCs helps you understand the new rules...

  • HIM Briefings

    Guiding Health Information Management professionals through the continuously changing field of medical records and toward a...

  • Briefings on Coding Compliance Strategies

    Submitting improper Medicare documentation can lead to denial of fees, payback, fines, and increased diligence from payers...

  • Briefings on HIPAA

    How can you minimize the impact of HIPAA? Subscribe to Briefings on HIPAA, your health information management resource for...

  • APCs Insider

    This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations...

Most Popular