Coding & Documentation

Use the date that you interpret the data and create your report, because that is when the service is complete. When you are reporting the complete service (technical and professional components), both the monitoring time required in the code descriptor and the interpretation and report should be completed before billing. If you are reporting only technical components (recording or scanning analysis with report), the date of service is the date the monitoring concludes based on the time in the code descriptor.

Report inhalation treatment with an MDI with the same CPT code you would use for treatment with a nebulizer: 94640, “Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes and/or for diagnostic purposes such as sputum induction with an aerosol generator, nebulizer, metered dose inhaler, or intermittent positive pressure breathing (IPPB) device.” However, your practice would not report a charge for medications used in this case because the patient supplies them.

If specially trained clinical staff perform the analysis and issue the report, the appropriate code would be 92227. If the ophthalmologist (or another qualified health care professional under direction of a retinal specialist) performs this interpretation then the correct code would be 92228. For retinal imaging for detection or monitoring of disease with point-of-care automated analysis, report code 92229.

Following the E/M guideline changes of 2021, when you provide ongoing management of a chronic condition such as ADHD, you should report an established patient office E/M service code (99212-99215) based on the medical decision making (MDM) necessary to manage the condition during that visit, including prescription drug management. Chronic illnesses without severe exacerbation or progression are typically level-3 or level-4 problems depending on how many there are and how stable they are. Deciding to continue the same medication and same dose is considered prescription drug management, which is level-4 risk.

As an alternative to coding based on MDM, you can code the visit based on your total time spent on the date of the encounter, regardless of whether that time was spent face-to-face or in counseling and/or coordination of care.

Yes, if the condition has not been fully repaired, report an ICD-10 code for it (probably one from Q20 through Q26.9, depending on the nature of the heart condition). Congenital heart defects may be partially repaired or even go undiagnosed until adulthood. They should be reported when the condition is evaluated or managed, or when it affects the management of other conditions. However, if the condition was fully repaired, report Z87.74, “Personal history of (corrected) congenital malformations of heart and circulatory system,” not a code for the prior condition.