Pediatric Coding Alert

Capitalizing on reimbursement for treating bee-venom-triggered anaphylaxis in the office depends on knowing if the service qualifies for critical care codes, and if it doesn't, which codes to use instead.

Although some pediatricians and coders think that 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( each additional 30 minutes [list separately in addition to code for primary service]) are for hospital use only, you may use these high-paying codes in the office if you follow CPT's guidelines for reporting critical care services, says Diane M. Minard, CPC, pediatrics coding specialist for Dartmouth Hitchcock Medical Center in Lebanon, N.H. The Medicare Physician Fee Schedule, which many private payers use as a guide, pays a geographically unadjusted nonfacility rate of $210.07 for 99291 and $107.79 for 99292.

In some instances of anaphylaxis due to bee or wasp venom, the patient's condition may require critical care services. For instance, a child who has an anaphylactic reaction to a bee sting may experience respiratory distress, vascular collapse, shock, urticaria (hives), angioedema and pruritus. If the episode meets the criteria for billing critical care services, using a higher-level office visit code such as CPT 99214 (Office or other outpatient visit for the E/M of an established patient physicians typically spend 25 minutes face-to-face with the patient and/or family) instead of 99291-99292 will cost your practice $130.24. But before you start reporting critical care codes, make sure you know the rules.

CPT defines a critical illness or injury as one that impairs one or more vital organ systems creating a high probability of imminent or life-threatening deterioration in the patient's condition. Therefore, if the severe systemic reaction to the insect sting becomes life-threatening and affects one or more of the child's vital organ systems and the pediatrician provides direct medical care, critical care services may apply, Minard says. For instance, the child may have difficulty breathing and go into shock. However, the physician must continue these life-sustaining services for 30 minutes to qualify for 99291.

Although the pediatrician does not usually provide these services in the office for an extended period of time, she may perform them until the patient can be transported to a hospital or critical care unit. If the physician attends to a critically ill pediatric child (24 months of age or less) and provides direct critical care in the transportation vehicle for a minimum of 30 minutes, you should report 99289 (Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport) and +99290 ( each additional 30 minutes [list separately in addition to code for primary service]) depending on the amount of face-to-face time documented, Minard says.

Note: Because the initial pediatric (99293, Initial pediatric critical care, 31 days up through 24 months of age, per day, for the E/M of a critically ill infant or young child) and neonatal (99295, Initial neonatal critical care, per day, for the E/M of a critically ill neonate, 30 days of age or less) critical care codes are per-day codes, which include a full day (global) of critical care services starting with the hospital admission day, this article refers to hourly critical care services (99291-99292) only. The pediatrician would not use 99293/99295 unless he or she admits the patient to the hospital and continues to provide and, therefore, bill for these services, says Jeffrey Linzer Sr., MD, MICP, FAAP, assistant professor of pediatrics for the division of emergency medicine at Emory University School of Medicine in Atlanta, and emergency medical services coordinator for the emergency pediatric group at Children's Healthcare of Atlanta at Egleston. If the patient is less than 2 years of age, however, and subsequently qualifies for 99293 or 99295, you may separately report 99291-99292 provided in another outpatient setting, such as the office or emergency department.

In many instances of anaphylaxis, the child may respond to treatment before qualifying for the 30 minutes necessary to bill 99291. For instance, a mother brings in her 5-year-old daughter who was stung by a yellow jacket. The sting site shows generalized signs of swelling and redness. During the examination, the child begins to wheeze. Her blood pressure drops. She shows signs of abdominal cramping and altered consciousness. The pediatrician intramuscularly administers (90782, Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) 2.5 mg of dexamethasone acetate (J1094, Injection, dexamethasone acetate, 1 mg) and 0.18 ml of epinephrine (J0170, Injection, adrenaline, epinephrine, up to 1 ml ampule). After about five minutes, the child's signs begin to subside, and the pediatrician gives a shot of 25 mg of diphenhydramine hydrochloride (J1200, Injection diphenhy-dramine HCl, up to 50 mg) and a nebulized albuterol treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device). The child's condition is stable within 15 minutes. The physician and a nurse monitor the child off and on over the next three hours.

Although the patient's symptoms were initially life-threatening, the child showed signs of organ stability prior to reaching the 30 minutes of instability necessary to bill critical care services. Consequently, you should report a high-level E/M code, such as 99214 or 99215 ( physicians typically spend 40 minutes face-to-face with the patient and/or family), in addition to the procedures and drugs, Linzer says. Append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the E/M code if the payer requires it, to show that the office visit is a significant, separately identifiable service from the procedures. Some insurers may also require you to add modifier -51 (Multiple procedures) to the subsequent injections (90782, 90782-51) or include them in the E/M.

Another area that you may inadvertently sacrifice is reporting prolonged services. "To capture extra time over that included in the office visit, you may bill 99354-99355," Minard says. Because these codes encompass direct face-to-face contact, the pediatrician must provide direct care to the patient and document the start and stop times.

"Although the patient may be physically in the office for three hours, you should report the prolonged service code only for the time the physician has direct contact with the patient," Linzer says. The time does not need to be continuous. For instance, if the pediatrician in the above scenario codes 99215 after spending a total of 120 minutes face-to-face (120 minutes of total face-to-face time - 40 minutes of 99215 = 80 minutes of prolonged service) with the patient, she should also report +99354 (Prolonged physician service ... requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient E/M service]) for the first additional 30-74 minutes of direct patient care time and +99355 ( each additional 30 minutes ) for the additional six minutes. "Because these are add-on codes, they do not require modifier -25," Linzer adds.

Another code that you should report for your pediatrician's services in treating an anaphylactic reaction is 99058 (Office services provided on an emergency basis). Because the patient's clinical condition demands immediate physician care and requires the doctor to interrupt her or his normal schedule to see the patient, you should also report 99058, which is modifier -51 exempt, Linzer says. And, unlike prolonged services, which exclude billing critical care codes, you may report the emergency code with either 99211-99215 or 99354-99355.

Payment for the emergency service, however, may prove difficult. Because the Blue Cross Blue Shield of Massachusetts fee schedule does not contain the code, many insurers deny 99058. But you should always try billing the service, Minard says. CPT requires reporting to the highest specificity possible and coding for the entire event.