Pediatric Coding Alert

In an effort to infuse their offices with added reimbursement, many pediatric coders are making fraudulent mistakes when reporting 90780-90781. Make sure you're not sucking the legality out of this extra revenue and risking wearing orange.

With 90780 (Intravenous infusion for therapy/ diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 ( each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) ranking in the list of the top-50 most-performed pediatric procedures, you probably encounter these codes regularly. But do you really have these codes down pat?

Many coding experts recommend reporting prolonged services in addition to the rehydration codes, a practice that CPT specifically disallows. In addition, you may wonder about the correct combination of infusion codes to assign. So inject your practice with a coding review by trying your hand at an infusion scenario and answering the questions that follow.

Suppose a grandmother brings to a pediatrician's office her 10-year-old grandson who has gastroenteritis. The physician documents history, evaluation and medical decision-making that equate to a level-five established patient office visit. Aregistered nurse under a pediatrician's supervision administers an intravenous (IV) infusion of 33 mg of Phenergan to treat the child's nausea and vomiting and 500 ml of 5 percent dextrose/normal saline for three hours to rehydrate the patient. Although the pediatrician is not in constant attendance, she checks on the patient every 15 minutes.

In this example, the pediatrician performs a level-five established patient office visit, which you should bill with CPT 99215 (Office or other outpatient visit for the E/M of an established patient physicians typically spend 40 minutes face-to-face with the patient and/or family), says Dalrona Harrison, RN, BS, CCS-P, CPC, approved American Academy of Professional Coders Professional Medical Coding Curriculum instructor and coding manager for Via Christi Medical Management in Wichita, Kan. The E/M service involves the history, evaluation and medical decision-making, which led the pediatrician to determine that the patient needed IV infusion.

To indicate that the history, evaluation and medical decision-making involved with 99215 are significant and separately identifiable from the minor E/M included in 90780-90781, you should append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 99215. "The modifier denotes the work that was necessary based on the patient's condition and then resulted in the administration of IV fluids and drugs," Harrison explains.

After reporting the E/M service, you should consider coding for the fluid administration. For the first hour of infusion, you should use 90780, Harrison says. To recoup the two additional hours, assign 90781 x 2.

If you didn't get the answer right, you're not alone. The majority of errors for claims involving infusion occur with the application of these two codes. In fact, you may have reached the incorrect answer due to one of three pitfalls.

The most common mistake that coders make is not billing for the entire infusion time, Harrison says. In the above example, in which the total time is three hours, you may have billed 90780 but not charged for the additional two units of 90781, she says. This difference will cost your practice $43.40 based on the Medicare Physician Fee Schedule (MPFS), which gives 1.16 relative value units (RVUs) to 90780 and 0.59 RVUs to 90781. (Because children do not qualify for Medicare, pediatricians rarely file Medicare claims. The MPFS, however, gives a geographically unadjusted basic rate to compare insurers to.)

Another typical error is missing the direction that 90781 is "each additional hour," Harrison says. For instance, you may have coded 90780 and 90781 but omitted the additional unit of 90781. Failing to pay attention to the "per additional hour" descriptor will cut $21.71 from the claim.

Make sure you also capture all the time associated for procedures that do not continue for a full additional hour. For claims that do not meet the time criteria for 90780-90781, such as one and a half hours of total infusion, you should append modifier -52 (Reduced services) to the infusion code (90780, 90781-52), which shows that the physician performed some work, but not all that the code requires, says Yvonne Hoiland, CPC, CPC-H, RCC, an infusion coding specialist and senior coding consultant for Coding Continuum Inc. in Tucson, Ariz.

Perhaps the costliest mistake that you could make is not realizing how to bill an add-on code. "Physicians sometimes bill 90781 by itself, but because it is as an add-on code it must be charged with a primary procedure, which in this case is 90780," Harrison explains. Listing an add-on code without the primary code will probably result in the payer denying the claim.

In addition, 90780-90781 include the cost for the infusion only. "In a physician office setting, you should always separately report the supplies and drugs," Hoiland says. Unfortunately, not all payers reimburse for these items, she says. For the 33 mg of Phenergan, report J2550 (Injection, promethazine HCl, up to 50 mg). Assign J7042 (5% dextrose/normal saline [500 ml = 1 unit]) for the 500 ml of saline. If an insurer does not accept HCPCS level-two codes, you should instead bill 99070 (Supplies and materials [except spectacles], provided by the physician over and beyond those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]). Because the general supply code does not specify the items used, you should include the drugs administered and expect an uphill battle with payers.

Regardless of the scenario, CPT section guidelines state that you should not use 90780-90781 in addition to prolonged services codes (99354-99355, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...).

"Because both services are time-based, CPT views billing infusions with prolonged services as 'double-dipping,'" Hoiland explains. "Although some instances may meet the criteria for 99354-99355, these services are inherently part of the infusion code, which is why 90780-90781 require direct physician supervision." Consequently, using both sets of codes would be double-dipping.

Therefore, if the situation appears to qualify for 99354-99355 and 90780-90781, you will have to report one code set only. Because 99354 ($121.04) and 99355 ($112.95) reimburse at a higher rate than 90780 ($42.68) and 90781 ($21.71), when appropriate, report prolonged services instead of the infusions, Harrison says. When using 99354-99355, bill for the total duration of face-to-face time that the physician spends on a given date providing prolonged services, even if the time spent is not continuous.

Harrison and Hoiland say the claim for the infusion scenario should be coded: