An established patient was seen for croup with stridor. The physician reported evaluation and management (E/M) code 99214 because a detailed examination and moderate-level medical decision-making were performed and documented. A pulse oximetry was performed and Decadron was administered by intramuscular injection. How should this visit be reported?

The services would be reported with Current Procedural Terminology code 99214 (office/outpatient, established patient E/M, detailed). Modifier 25 should be appended to the E/M service to signify that the visit was significant and separately identifiable from the other procedures performed on the same day. The pulse oximetry should be reported with code 94760. The Decadron is reported using Healthcare Common Procedure Coding System (HCPCS) Level II code J1100 (dexamethasone sodium phosphate, 1 mg [Decadron]). If Decadron LA was administered, report HCPCS Level II code J1094 (dexamethasone acetate). Note that some payers will require reporting of the National Drug Code instead of the...

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