Pediatric Coding Alert

Proper use of consultation or hospital codes allows a pediatrician co-managing a complicated case, such as peritonitis, to coordinate his or her coding with other specialists caring for the same patient.

For instance, the pediatrician admits a 13-year-old female to observation (99218-99220) for generalized abdominal pain (789.07). Early the next morning, the pediatrician re-examines the patient to find severe right lower quadrant pain (789.03), a fever of 102 degrees, diffuse abdominal tenderness, guarding and absent bowel sounds. The pediatrician immediately calls the general surgeon, who takes the patient to the operating room where appendicitis with a ruptured appendix (540.0 ) is found. The surgeon performs an appendectomy (44960, appendectomy; for ruptured appendix with abscess or generalized peritonitis), and the pediatrician transfers the care to the surgeon.

The patient recovers slowly for seven days, experiencing persistent fever. The primary care pediatrician manages the peritonitis (540.0), co-managing the patient with the general surgeon.

If, for instance, the surgeon requests a consultation because he or she may not feel qualified to handle antibiotic management for such a complicated pediatric case, the pediatrician can use the inpatient consultation codes (99251-99255) for the initial visit and the subsequent hospital care codes (99231-99233) for followup visits.

Absent a request for a consultation by the surgeon, the pediatrician could still bill for co-managing the patient. For example, the pediatrician could bill antibiotics management (but not a consultation), and the surgeon could bill the post-operative care following the appendectomy. Under these circumstances, the pediatrician could still bill hospital care codes (99231-99233) for all subsequent days.

Documentation Is Critical

There must be justification for the pediatrician to manage postoperative medication, says Susan Callaway, CPC, CCS-P, an independent coding consultant and educator based in North Augusta, S.C. Some situations do occur as exceptions, but in general the surgeon should be able to manage this on his or her own, and the presence of the pediatrician might be questioned, she says.

A pediatrician who is billing the same case as a surgeon must have a well-documented reason for doing so (beyond providing support to the family). Documentation should be based on the elements of history, physical and medical decision-making and should focus on the problem being managed.

The surgeon and pediatrician are co-managing the case only in a clinical (not a CPT) sense. Coders would not append the co-management modifiers modifiers -54 (surgical care only) and -55 (postoperative management only) to any of the services because they would result in a reduction of the surgeons fee. The primary care pediatrician would not be managing all postoperative care, only that pertaining to the peritonitis, therefore the co-managing modifiers would not be appropriate. The surgeon would remain involved in the case for postoperative surgical management included in his or her surgical package (90 days).