Pediatric Coding Alert

Compare your answers to those of our experts.

Answer 1:
In this scenario, you can only bill for the hospital admission. So, you would bill 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) depending on whether the medical decision making was of low, moderate, or high complexity.

Why? As Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, sees it: "If a patient is being admitted to the hospital, the admitting provider would consider all previous services, such as office, emergency room, and observation as included in 99221-99223, when performed on the same date of service."

Or, as CPT^® guidelines state: "When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service ... evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission." Because of this, the guidelines go on to note that you cannot report other evaluation and management (E/M) services such as 99201-99215 (Office or other outpatient visit ...) or 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual ...) separately.

Answer 2:
Because the physician does not see the patient until the following day in this scenario, you can now bill the E/M service separately from the hospital visit. So, you can report 99201-99215 or 99381-99387 on the first day and 99221-99223 on the second.

Why? The descriptors for 99221-99223 state that they are for hospital care per day (italics added). So, you can bill for the previous day's E/M service separately from, and additional to, the hospital visit. And if the patient stays in the hospital longer than the initial day, you can bill 99231-99233 (Subsequent hospital care, per day ...) depending once again on the complexity of the medical decision making.

Or, in Johnson's words, "Since the services, the office visit, and the initial hospital visits are on separate dates of service, there is no inclusion, and the provider could bill for each date of service separately."

Answer 3:
The answer here depends on a number of things: whether the physicians are billing under the same tax ID number (TIN); if the patient was admitted as an inpatient or for observation; and, if the patient was admitted for observation, the length of time the patient spent under observation.

"If the pediatricians in question are billing under separate TINs," Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, argues, "and assuming this was an inpatient admission, then the first pediatrician would bill an initial hospital care code from 99221-99223, and the second pediatrician would bill from 99238-99239 (Hospital discharge day management ...) for the corresponding discharge.

You would document a patient admitted and discharged by physicians billing under the same TIN, however, with 99234-99236 (Observation or inpatient hospital care,  for the evaluation and management of a patient including admission and discharge on the same date ...), which covers both inpatient and observation statuses.

But if the patient was admitted to observation, you would bill using 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ...) for pediatricians billing under the same TIN, while the first pediatrician would bill 99218-99220 and the second 99217 (Observation care dischargeday management ...) when billing under separate TINs, according to Moore.

Why? Medicare and payers who follow its guidelines abide by the CMS decision that when "a patient receives observation care for less than 8 hours on the same calendar date," the physician should report "from CPT^® code range 99218-99220" (Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf).

Answer 4:
"Assuming the patient is not covered by Medicaid," Moore argues, "and assuming that that the payer in question still recognizes and pays for CPT^® consultation codes," you could bill 99251-99255 (Inpatient consultation for a new or established patient ...). However, "as many payers no longer recognize the CPT^® consultation codes, your pediatrician will need to report an initial hospital care code for his or her service," Moore continues.

Why?  Again, this is due to CMS guidelines, which state that "physicians may bill initial hospital care service codes (99221-99223), for services that were reported with CPT^® consultation codes (99241–99255) prior to January 1, 2010, when the furnished service and documentation meet the minimum key component work and/or medical necessity requirements" (Source: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2282CP.pdf).