Pediatric Coding Alert

Sometimes a call comes in the early-morning hours. It is from the hospital; the pediatrician is being summoned because a patient is in crisis. The coding dilemma involved in this scenario is that the patient will be seen again, later that same day, by the pediatrician. How can you code for the 2:00 a.m. visit to the hospital as well as the regular rounds done later that day? You cant bill for two evaluation and management (E/M) services on the same day. The subsequent hospital care codes (99231, 99232 and 99233) can be used only once per day, as well.

There are several alternatives to this problem. The main choice is between coding to a higher level, or using different codesespecially critical care codesthat might be appropriate.

1. Coding to the next level. This is probably the simplest way of handling the chargeand you will have to do it regardless of what other codes you use. You take the complexity of the visits and the time involved, and add them up to come up with a higher-level visit, says Richard H. Tuck, MD, FAAP, of Primecare Pediatrics in Zanesville, OH. This isnt perfect, because almost by definition, any call you get that necessitates you going to the hospital in the middle of the night is likely to be a CPT 99233 . The fact that you came in at 2:00 a.m. almost always means the visit involves high medical decision-making, says A.D. Jacobson, MD, FAAP, of Pediatric Associates in Phoenix, AZ, and editor of the AAPs Coding for Pediatrics. So in any event, you will probably be coding 99233 once for the 2:00 a.m. visitno matter how many times you see the child later on during that day, or how intensive the child is. But this drawback can be more tolerable by the fact that you may be performing other procedures in addition to the hospital visit itself (see item 2 below). One example would occur when a child is admitted with abdominal pain, says Jacobson. You dont know what the problem is, and the child seems to be doing well. Then, at 2:00 a.m., the child has severe pain. You go in and see him, and you call the surgeon, says Jacobson. The surgeon comes in at 5:00 a.m., and its appendicitis. Then you see the child postop. This would be a 99233 for the day, says Jacobson.

2. Billing for procedures. There may be services you are performing as well as the visit in the middle of the night, says Jacobson. A typical scenario is when a child is admitted with a diagnosis of croup. The child gets worse at night, and the pediatrician is called. You intubate the patient and put him on a ventilator, says Jacobson. This merits a 31500 (intubation, endotracheal, emergency procedure) charge in addition to a critical care code (see item 3 below). Even if the patient is not critical, however, and you are just using a regular hospital code, you should remember to add any procedures. For example, if you do a venipuncture on a child under the age of 3, code 36406 (venipuncture, under age 3 years; femoral, jugular or sagittal sinus). If the venipuncture is on an older child, use 36410* (venipuncture, child over age 3 or adult, necessitating physicians skill [separate procedure], for diagnostic or therapeutic purposes. Not to be used for routine venipuncture).

3. Billing for prolonged services. In the prior scenario of the child with croup, you should also keep track of the time involved, says Jacobson, because you may be able to bill for prolonged services. You may spend well over the 35 minutes allotted by CPT to 99233, particularly if you are adding in the one, two, or even three visits you make later in the day. The prolonged services codes are 99356 for the first hour of inpatient prolonged services, 99357 for each additional 30 minutes. If you spend an hour and 15 minutes on the child, for example, you can bill 99356 in addition to 99233.

Calculation tip: Prolonged services are added to the E/M services code, not aggregated with it. Therefore, you cant bill prolonged services for 99233 unless you have spent at least half an hour in addition to the time for the E/M service. The first half hour is not billable separately.

Prolonged services do not have to be provided continuously, so keeping track of your time spent per day with the patient is important. While 99356 and 99357 are for face-to-face patient contact, there are also prolonged services codes for use when there is no face-to-face contact, such as when you are reviewing records, communicating with the family, or communicating with other professionals. These non-face-to-face prolonged services codes are 99358 and 99359. Note that time spent with parents counts as face-to-face. So does anything done in the hospital in regard to the patient.

Documentation tip: Time must be explicitly documented.

4. Billing for critical care codes. Nine times out of 10, says Jacobson, middle-of-the-night calls to the hospital warrant critical care codes. Depending on what procedures you are providing during the crisis visit, it may be more appropriate for you to use the critical care codes than to use 99233 and procedure codes. The definition of critical care, according to CPT, is the care of the unstable critically ill or unstable critically injured patient who requires constant physician attendance. The codes (99291, for the first hour; and 99292, for each additional 30 minutes) include certain procedures: cardiac output measurements (93561, 93562), chest x-rays (71010, 71020), blood gases and information data stored in computers (such as ECGs, blood pressures, and hematologic data), gastric intubation (91105), temporary transcutaneous pacing (92953), ventilator management (94656, 94657, 94660, 94662), and vascular access procedures (36000*, 36410*, 36415*, 36600*).

Critical care codes do not include endotracheal intubation, so, in the case of the child with croup, you could bill 99291 and 99292, depending on how much time you spent, as well as 31500. Critical care codes do not require bedside attendance, but do require that the work is directly related to the individual patients care, according to CPT. Jacobson explains that this means, for the child with croup, you may start the critical care code time clock at the 2:00 a.m. visit and continue it throughout the day for the time spent caring for this child, if the child remains critical. You make a number of phone calls about it during the day, he says. You see the child several times during the day. Youre documenting what youre doing. You could be checking blood gasesyou write it down.

Tip: Like the prolonged services codes, you can bill only if you spend 30 minutes or more on critical care.

5. No after-hours codes. Its 2:00 in the morning, that should qualify for after-hours, you may be thinking. Unfortunately, that is not the case. After-hours codes are only for outpatient use, says Jacobson. In a way, this doesnt make any sense at all. The purpose of the after-hours charge is to compensate the physician for the extra work involved outside of office hours, because there is a lot more stress for the physician when called to the hospital for a crisis than when called to the office after hours. Its much easier to see a little baby with an ear infection in the office at 2 a.m. than to see a child with cardiac arrest in the hospital at 2:00 a.m., says Jacobson. Its a very traumatic call. (For more information on after-hours codes, see article entiltled Use After-Hours Codes Appropriately to Receive Optimal Reimbursement in this issue.)