Pediatric Coding Alert

It sounds simple, but it's easier said than done: If you're not keeping track of the extra time you're spending providing services to children with serious chronic conditions, you're losing out on hard-earned reimbursement for patients who can consume lots of a pediatrician's time and energy.

But take heart. A thorough grounding in the spectrum of CPT codes available for children with significant long-term chronic problems, such as children with spina bifida, cystic fibrosis and cerebral palsy, will help you capture pay for the services you're providing these patients.

According to the American Academy of Pediatrics'(AAP) coding guide, "Coding for Pediatrics 2003," the CPT codes for children with special healthcare needs are the same as for children without chronic conditions. Even so, it's up to pediatricians to determine how best to use code groups such as the prolonged services, case management and preventive services codes to report care they provide for chronically ill children.

Pediatric coding experts suggest using the following code groups and offer seven tips for fine-tuning your chronic healthcare coding accuracy.

1. 99201-99215:Record Time of Highest-Level E/M Visits

To accurately report problem office visits for new and established patients with chronic illnesses, pediatricians should remember to use time spent during the visit to select the higher-level E/M codes.

The time physicians spend with many of these patients exceeds the typical times included in CPT, even at the highest levels, says Richard A. Molteni, MD, FAAP, vice president and medical director at Children's Hospital and Regional Medical Center in Seattle.

Molteni recommends using the "consultation rule" when more than 50 percent of the visit involves counseling or coordination of care (which is extremely common in these patients) to reach the highest E/M level when the degree of history or physical exam would not allow that.

If, for instance, a pediatrician sees an established, wheelchair-bound spina bifida patient in the office for chronic constipation and spends a total of 40 minutes, with 25 minutes of the visit spent on counseling the patient and her mother on disimpaction methods, you would report 99215.

Physicians should also be especially vigilant about reporting the correct ICD9 Codes because these support medical necessity for higher-level E/M codes.

The problem is that pediatricians have been coding for the acute events and not for the chronic illness, says Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.

"If you think the chronic illness diagnosis has an impact on the acute illness diagnosis, then you should code both," Rappo says. "When a child with spina bifida (741.9x) has recurrent ear infections, that's still a more complicated patient than a patient who gets ear infections without spina bifida. In this case, code both the chronic illness and the otitis media (382.9), and document both."

2. 99354-99359:Keep Track of All Prolonged Services

When a patient's chronic condition requires excess provider time beyond the norm for an office visit, you'll need to add the appropriate prolonged services code to the E/M code.

Prolonged services codes are defined by time, according to the following guidelines: If the additional time is less than 30 minutes, you would not report a prolonged services code. For more than 30 minutes, add +99354 (Prolonged physician service in the office ... first hour) to the appropriate E/M code. If the extra provider time is more than 75 minutes, report 99354 for the first hour and +99355 ( each additional 30 minutes) in addition to the appropriate E/M code.

Both face-to-face and non-face-to-face prolonged services codes are crucial to coding care for children with special healthcare needs, says Joel Bradley Jr., MD, a practicing pediatrician with Premier Medical Group in Clarksville, Tenn., and editor of the AAP's coding guide.

For instance, a pediatrician performs a comprehensive office examination, which includes complex medical decision-making, for a new cystic fibrosis patient. The visit takes 60 minutes to complete; afterward, the pediatrician spends an additional 30 minutes answering the patient and parents'questions. In this case, you would report 99205 for the office visit and append 99354 for the extra 30 minutes of counseling related to the patient's cystic fibrosis (277.02).

Don't Let Time (Reviewing Charts) Slip Away

When you spend extra non-face-to-face time either before or after direct patient care performing such services as reviewing charts and communicating with other professionals, report 99358 with the appropriate E/M code for the first hour of time spent and 99359 for each additional 30 minutes on a given service date.

If, for example, a pediatrician spends 30 minutes reviewing the charts of a new cerebral palsy patient without the patient present after spending 45 minutes providing a comprehensive examination in the office, he or she would bill 99358 in addition to 99204.

Typically, providers use the non-face-to-face prolonged services codes because these are clearly for such services as chart review, Rappo says.

 "Prolonged services codes are usually for time spent away from the patient, not face-to-face," Rappo says. If at the end of the day, you're reviewing a stack of records on the child and going through it, that's prolonged services.

Remember that you may report prolonged services codes only once per day, even if the time the physician spends with the patient is not continuous on that date, CPT states.

Append Modifier -21 for Extended E/M Services

Attaching modifier -21 (Prolonged evaluation and management services) to a high-level E/M code (such as 99205 or 99215) when you spend more time than usual performing a service is another way to account for extra time spent with a chronically ill patient, Molteni and Bradley say.

If you're not sure whether to append modifier -21 or use a prolonged services code, ask your staff what insurers allow, Rappo says.

Bradley says that payers often do not reimburse for modifier -21, but in certain situations this is a legitimate way to bill for extra time.

For instance, in the course of a high-level office visit, such as 99215, a physician spends an extra 25 minutes performing a service, such as instructing a spina bifida patient's parents regarding shunt care with the patient present. You could append modifier -21 to 99215. Because the amount of face-to-face time (25 minutes) with the patient during the visit exceeded the 40-minute limit for 99215 but is not enough to bill a prolonged service code, appending modifier -21 would be appropriate. Some payers may require a report attached to the claim, explaining why the circumstances required extra time and supporting the use of modifier -21.

3. 99371-99373: Phone Codes for Case Management

Coding experts point out that pediatricians often do not report the time they spend on the telephone managing care for chronically ill children because many insurers do not reimburse for telephone time.

Telephone management is critical for the care of these patients, but it is usually bundled into E/M services, Rappo says.

Even so, Rappo recommends negotiating telephone reimbursement with insurers on an ad-hoc basis, depending on the severity of the chronically ill child's disease. For instance, one of his chronically ill patients was on a ventilator in the hospital and required ventilation at home. He called the insurer to ask about billing for telephone time spent coordinating the care of this patient and was told he could report telephone time. So it's worth making calls to payers to arrange telephone reimbursement in special cases.

Report 99371 for brief calls; 99372 for calls of intermediate complexity and length, such as to discuss a new therapy for a cerebral palsy patient; and 99373 for complex care coordination, according to the AAP's coding guide.

Remember: As an alternative to billing the telephone codes, you can report the non-face-to-face prolonged services codes (99358-99359) for telephone time spent with referring agencies or home healthcare. Payers are more likely to reimburse for these codes than the telephone codes, coding experts say.

4. 99341-99350: Report Home Services

When a patient's condition is such that he or she can't come into the office, or the arrival of such a patient in the office would seriously disrupt office flow, the pediatrician may find that he or she must make a house call, Rappo says.

Report the appropriate code in the 99341-99345 range when visiting a new patient at home and 99347-99350 for home services to established patients when these visits are appropriate and cost-effective, Molteni says.

Bradley recommends reporting these codes, for instance, when visiting home-ventilator patients or children in hospice care. If, for example, the pediatrician spends 40 minutes of face-to-face time with an established, stable patient on home ventilation, examining the patient and making care assessment decisions, report 99349 (Home visit for the evaluation and management of an established patient, which requires at least two of three key components) for the visit.

5. Checkups Require Modifier -25

Children with chronic illnesses do have well-child checkups, but these visits can become complex because pediatricians typically end up providing services that also relate to the chronic illness.

Unless the documentation for the visit also indicates that the physician separately provided services related to the chronic condition, you'll lose reimbursement for the extra work. One way around this problem is to 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 appropriate preventive medicine code to reflect the separate, chronic condition-related services, pediatric coding experts say.

When a spina bifida patient, for example, comes in for immunizations and other well-child services, and the mother has questions about preventing tethered cord, "you're now talking about preventing complications of the illness," Rappo says. In this situation, you should append modifier -25 to the office visit code, he says.

Be sure to link the E/M code with modifier -25 to the appropriate ICD-9 code for the chronic condition, such as 741.9x for spina bifida.

6. 99401-99404: Bill Risk Reduction

Because these codes aren't for discussions of present problems, pediatricians use them infrequently.

Even so, providers who treat patients with chronic illnesses may need to make them and parents aware of possible complications and prevention strategies, Rappo says. For instance, a child with spina bifida may not have shunt blockages, tethered cord or renal stones yet, but the pediatrician will need to educate the patient and the parents about those possibilities. For those discussions, report a code in the 99401-99404 range, depending on the time spent in risk-reduction counseling.

7. 99374-99380: Report Care Plan Oversight

If you're supervising care for a patient who is in a hospice or receiving home health services, don't forget to report the care plan oversight codes (99374-99380).

Report the initial codes (99374 or 99377) when your supervision time exceeds 15 minutes during a 30-day period, according to the AAP coding guide. If you spend more than 30 minutes, you can report 99375 or 99378 for supervision over a 30-day period, depending on whether you are supervising home health or hospice care. Don't forget to document supervisory time in the patient's record.