Pediatric Coding Alert

Learn how to combine encounters to optimize your group practice pay
 
You can ethically maximize reimbursement for yourself and your partner when you treat an asthma patient on the same day if you combine your E/M services and nebulizer-related procedures.

When pediatricians in the same group practice perform same-day services and procedure, you may be tempted to bill separate claims. But this coding method will cost you E/M and procedure pay, as the following case study shows:
 
Test Your Dual-Encounter Coding

In pediatric group practices, you file claims under one tax identification number. So, if you have multiple same-day claims for a patient, the insurer won't recognize that different pediatricians performed the charges. That means the payer will reject the same-day E/M and possibly deny additional procedures as duplicative, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator in North Augusta, S.C.

Solution: Treat the pediatricians' services and procedures as one.

Challenge: See if you can combine multiple same-day services and procedures for an asthma patient who requires repeat nebulizer treatments. In the following real-world scenario, both pediatricians are in the same group and file claims under the same tax identification number.

The case: A mother brings her child who is having an asthma attack into your office at 9 a.m. for a sick appointment. Pediatrician A treats the child with two nebulizer treatments and an injection. The pediatrician spends 50 face-to-face minutes with the child, not including procedures. He codes the visit as CPT 99214 , and marks appropriate nebulizations, medications and injection codes.

At 4:10 p.m., the mother returns as a walk-in with the child, who is now wheezing and in distress. Pediatrician A has left for the day, so Pediatrician B sees the child and administers two nebulizer treatments with medications and an injection. He also calls emergency medical services (EMS) to transport the child to the emergency department. The pediatrician spends 70 face-to face minutes with the patient, not including procedures.

Combine Direct E/M Time

When two pediatricians in the same group treat a repeat asthmatic, you may not know how to report the day's services. In such situations, "What is the appropriate way to code for each physician's work for maximum reimbursement?" asks Kathy Wilborn, practice manager at Cook Children's Physician Network - Hurst Clinic in Hurst, Texas.

Hint: Don't treat each pediatrician in the above scenario as an individual.
 
If you bill an office visit for each pediatrician, the insurer will reject the second E/M as a duplicate service. To avoid a denial, one coder suggests billing 99214 for Pediatrician A and no E/M for Pediatrician B. But coding only one physician's services will cost you about $230 in service pay.

Better way: You should ignore the separate documentation and treat both E/M encounters as a single visit. Submit one office visit code for the day, says Joel F. Bradley Jr, MD, FAAP, a pediatrician for Premier Medical Group in Clarksville, Tenn. If Pediatrician B documents a level-five office visit, you should report 99215 for both office visits. The additional E/M level will add $36.96 to the claim. (Quoted prices are based on the 2004 National Physician Fee Schedule Relative Value File that private payers may adapt from Medicare.)

Watch out: Code 99215 captures only 40 minutes of E/M time. To bill for the 80 minutes beyond the 40 minutes CPT designates for 99215, you should report +99354 (Prolonged physician service in the office or other outpatient setting 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 evaluation and management service]) and +99355 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]), says Richard H. Tuck, MD, FAAP, a pediatrician in Zanesville, Ohio. The prolonged service coding assumes that the pediatricians spend 80 face-to-face minutes with the patient, not including procedures. Prolonged service codes 99354 (represents 60 minutes) and 99355 (for 20 minutes) each add $96.71 and $95.96 to your pay.

Don't forget to bill for the emergency visit. Because Pediatrician B treats the wheezing asthmatic on an emergency basis, you should use 99058 (Office services provided on an emergency basis) as an add-on code to the above E/M service.

Code 3 Duplicate Nebulizations

You should next focus on reporting the nebulizer treatments. Each pediatrician administers two treatments. Because you're filing one claim, you should report a total of four nebulizer treatments. For the first nebulizer treatment, report 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]), Bradley says.

You should append modifier -76 (Repeat procedure by same physician) to all subsequent inhalation treatments to indicate the patient received more than one inhalation treatment on the same date. The insurer is assuming Pediatrician A and Pediatrician B are the same provider (same tax identification number). So, modifier -76 applies to all subsequent treatments: 94640-76 x 3, Tuck says.

Report Total Daily Injections, Supplies

You should also bill the injection administration and epinephrine supply using units. "Report one unit of 90782 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; subcutaneous or intramuscular) for each injection administration of epinephrine," Tuck says. To indicate the amount of epinephrine the pediatricians administer, you should report J0170 (Injection, adrenaline, epinephrine, up to 1 ml ampule) using units.

Example: Pediatrician A administers two epinephrine injections containing less than 1 ml, and Pediatrician B gives one. You would assign 90782 x 3, J0170 x 3.

Did You Get the Right Answer?

You should report the codes in descending order. In summary, for the claim, you should assign: