The proper way to code this visit is 99214-25, 90765, 90766×3, G0332, Q4087x50, J7050; diagnosis codes: 357.81, 719.46.
The E/M visit would be coded 99214-25. The visit is a level 4 because the history is detailed and the medical decision-making was of moderate complexity. This is an established patient, so you only need two out of the three components to get to that level of coding. You need the modifier -25 to show the office visit was significant and separately identifiable, along with the following codes:
- 90765: This is the drug administration code for the initial hour of the infusion.
- 90766×3: This is used for each additional hour of the infusion (31 minutes or more constitute an hour).
- G0332: This HCPCS code is the pre-administration–related services for IVIg. This service is to be billed in conjunction with administration of immunoglobulin.
- Q4087x50: This drug would be coded as Q4087 with 50 units, because each unit is 500 mg.
- J7050: This is the code for normal saline.
July’s “Coding Corner” challenge (p. 11) read, “A 68-year-old female diagnosed with rheumatoid arthritis is scheduled for an arthrocentesis of the shoulder and the elbow.” The correct challenge is, “A 68-year-old female diagnosed with rheumatoid arthritis is scheduled for an arthrocentesis of the shoulder and the knee joint.”