Pediatric Coding Alert

The not-so-secret problem with emergency care is that if patients go to the emergency room, they have a much higher insurance payment than if they go to your office. And, the hospital gets a lot more money for seeing them than you doeven if the patient is there for a non-emergency problem, like abdominal pain that turns out to be a minor stomach bug. So its understandable that the primary care pediatrician, when faced with a walk-in emergency patient, wants to know if there is a code that would reimburse better than a standard sick-visit code.

Syed K. Naqvi, MD, of the Pediatric Clinic of Ripley in Ripley, TN often sees patients who walk in late in the afternoon as the practice is about to close.

If we refuse to see them, they will go to use the emergency room, which will be a higher charge to insurance, he states.

However, there is a different code pediatric practices can use when seeing unscheduled and emergency patients. If you use it in combination with an office-visit code, you will be getting extra reimbursement for the extra work done for an emergency patientif the carrier recognizes it as a separate procedure.

Services Provided on an Emergency Basis

The only reasonable answer is 99058, says Charles M. Vanchiere, MD, FAAP, CEO of Childrens Clinic of SW Louisiana in Lake Charles. 99058 is listed under Special Services and Reports; Miscellaneous Services, and is described as office services provided on an emergency basis.

You should definitely use an E/M services code for the appropriate level of service, says Vanchiere, who is chairman of the American Academy of Pediatrics RBRVS Project Advisory Committee (PAC). Regardless of what payers think, CPT categorizes 99058 as an adjunct to basic services. Procedures with code numbers 99000 through 99090 provide the reporting physician with the means of identifying the completion of special reports and services that are an adjunct to the basic services rendered, CPT states . The specific number assigned indicates the special circumstances under which a basic procedure is performed. Another example of this category is the after-hours code 99050.

Vanchiere cautions that it is essential to note the emergency nature of the visit in the chart if you want to use the 99058 code. It has to be well-documented that it really was an emergency, he says.

If the parent calls first, perhaps frantic about a very sick or injured child, and you tell them to come in right away, is it still an emergency that qualifies for 99058? That depends on how you run your practice, says Vanchiere. In this practice, 80 percent of the patients call the same day of service. Obviously, not all of those patients are emergencies. Vanchiere uses 99058 for patients who literally come in without an appointment.

By the way, its not a bad idea to have the parent sign a note saying, My child needs emergency medical care today, says Vanchiere. Thats especially important for Medicaid patients, he notes. If you have a note, then if the Medicaid carrier asks why you are seeing the patient so much on an emergency basis, you have that back-up, explains Vanchiere.

Comparing the Relative Values Heres how the relative value units (RVUs) add up when you start using 99058, compared to sick visits. Remember, youll be adding 99058 to the sick-visit code. A level 4 established patient office visit (99214) has a value of 8.7 RVUs ($78-$95 range according to the 1998 Physicians Fee and Coding Guide); a level 5 established patient office visit (99215) has a relative value of 14.0 ($123-$157 range); a level 4 new patient office visit (99204) has a relative value of 13.5 ($120-$149 range); and a level 5 new patient office visit (99205) has a relative value of 17.8 ($154-$201 range). 99058 has a relative value of 8.5 ($70-$100 range)