Pediatric Coding Alert

When pediatric patients have diabetes, they have special needs that make the entire coding picture very important. If pediatricians do not use all of the codes that are appropriate, and do not have a plan for proper billing, they run the risk of losing adequate reimbursement. These cases can take up an inordinate amount of time and are very involved in terms of decision-making. How can you manage these patients in your own practice without losing money? The comprehensive coding approach is the best answer. This includes:

1. Telephone codes. Theres a lot of telephone management, especially when the diagnosis is first made, says Joel Bradley, MD, FAAP, editor of the current edition of Coding for Pediatrics published by the American Academy of Pediatrics. Usually, these calls are daily for the first few weeks, he says. This is a situation in which you can legitimately bill the telephone codes, he says. Youll have quite a lot of telephone time, with parents and other providers. The telephone codes are listed under case management services, and there are three tiers for different levels of involvement: simple (99371), intermediate (99372) and complex (99373).

Insurance companies generally wont reimburse the telephone codes. But in the case of pediatric diabetes, says Bradley, they very well may love them. Why? Because your time spent on the phone with the parent will help keep the child out of the hospital. Write a letter to the insurance company telling them youll be billing for the phone codes, recommends Bradley.

2. Education. Some children take medication orally, but most must get injections. Blood sugar must be tested as often as six times a day, necessitating a finger prick each time. This is all done at home by the parent or, in the case of an older child or an adolescent, the patient may do it. The medication be given and the blood sugar tested, but the parent and child need to be trained in these procedures.

If the pediatrician does the teaching, then you could code an evaluation and management (E/M) services code (99212-99215). If the nurse does the teaching, the highest code you could use would be CPT 99211 . Considering that it may well take an hour for the initial teaching, you may want to take advantage of a diabetes management program that the familys insurance plan offers. In this program, a nurse visits the home and provides teaching on injection techniques, blood sugar testing and other issues as well, including diet. My only objection to using the patients insurance plan for education is that there is no communication with the physician, says Bradley.

There is another option, though: code 97535 (self care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one-on-one contact by provider, each 15 minutes). If you read the descriptor, it makes sense, says Bradley. Safety procedures can apply to how to respond if the blood sugar is low, he says. But if the nurse is doing the education, I think it might be a stretch to bill 97535. It would be a stretch, says Bradley, because under the therapeutic procedures heading of CPT the category where 97535 is found the introduction says, physician or therapist required to have direct (one-on-one) patient contact. A nurse is neither a physician nor a therapist. I wouldnt bill 97535 for diabetes education until getting it approved by the insurance company, he says. But you could make an argument for it in the case of a diabetic. Finally, if the hospital you are affiliated with has a diabetes education program, you should look into it for your patients, says Bradley. You will have communication with the educator, and the billing for the education will be taken out of your hands entirely the hospital billing staff will do it.

3. High-level office visits for common illnesses. A child who comes in with the flu normally wouldnt warrant a 99215. But a diabetic with the flu probably will. When a diabetic child presents with an acute illness such as the flu, there may be vomiting, and this makes the diabetes worse, says Bradley. Something like strep throat, flu or gastroenteritis can make a diabetic much sicker than another child, he says. Some pediatricians will give a medication for nausea, and then try to give oral fluids, he says. Oral rehydration therapy takes from two to three hours. During this time, the child would remain in an examination room with a parent, with the pediatrician checking in periodically. On the claim form, make sure you indicate the primary diagnosis as the acute illness, as well as diabetes as the secondary diagnosis. If the patient does go on to develop ketoacidosis (250.1x), that would be the primary diagnosis.

4. Prolonged services. If you spend a lot of time with a child who has a chronic condition like diabetes, you better get used to billing prolonged services codes, says Bradley. About half of insurance companies pay for prolonged services, he says. These codes are 99354 (first hour) and 99355 (each additional 30 minutes). These are add-on codes to be used in addition to the E/M services code and require face-to-face patient contact for the entire time. They cannot be used when you merely check on a patient who is being rehydrated, and you are just popping your head in between other patients.

5. Intravenous hydration. In the case of a diabetic with an acute illness who requires hydration due to vomiting, some pediatricians choose to perform intravenous hydration in the office. The code for this is 90780 (IV infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). Each additional full hour should be billed with add-on code 90781. It usually takes an hour or two for intravenous hydration, says Bradley. You would also bill for the office visit probably a 99215. You should append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit because you will be doing much more than the hydration.

Tip: Some pediatric billers say insurance companies do not accept modifier -25. But this seems to be improving. I see things improving, with more companies accepting modifier -25, says Richard Tuck, MD, FAAP, a member of the AAP coding and reimbursement committee. And if we dont continue to use it, theyll never recognize it, adds Tuck, who practices with Primecare Pediatrics in Zanesville, Ohio.

6. Hospital admission. Sometimes, despite all the work you do seeing a patient in the office, later that day the child must be admitted to the hospital. Although the emergency room physician may admit the child, or, in an academic setting, a pediatric resident would do the admitting, the right thing would be for the pediatrician who is treating the child to do the admission, says Bradley. This is the right thing clinically. But remember that you can only bill one E/M code per day. So even if your office visit with the child in the morning was a 99215, you will not be able to bill that visit separately if you are also billing a hospital admission. But you can use the work involved in the office visit when determining what level hospital admission to bill. For example, if the office visit were a 99215, and the hospital admission itself only justified a 99221, you could upcode the hospital admission to a 99223.