Pediatric Coding Alert

Catch: July 4th can fall under 99050 or 99051--your hours make the difference

You can't get insurers to ante up additional pay for special service codes unless you watch for scenarios that could take these six add-on codes.

CPT 2006 rewrote the special service codes, which are always reported in addition to an E/M service. See if you know which code applies in the following cases.

Discover Add-on Code for Sunday E/M

Case 1: Although your office is closed on Sundays, you decide to see a patient due to ear drainage with puss, severe ear pain, and high fever on Sunday afternoon. You diagnose an ear infection without ear-drum rupture (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum) and write a prescription for Amoxicillin.

Answer: When an office is closed but you come back to see a patient, you can use 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or Sunday], in addition to basic service) in addition to the E/M service code, such as 99213-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...), says Richard Lander, MD, FAAP, with Essex-Morris Pediatric Group in Livingston, N.J. You can apply this code anytime the office is closed and a patient is seen including:

• Sunday afternoon

• Independence Day

• Christmas.

Try this: If an insurer balks at paying for 99050 for service on a Sunday afternoon, show them the cost savings of in-office care. "Tell the representative that you'd be happy to send patients on Sundays to the emergency department instead of treating them in the office," Lander says. Compare the visit-plus-99050-payment rate to the significantly higher ED-visit rate (generally about eight times more than a physician visit).

Consider This Code for Working Holidays

Case 2: To serve the pediatric community, your clinic remains opens on Independence Day and your two staff pediatricians see 26 patients.

Answer: For seeing patients on a holiday that your office did not close for, you may report 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) per encounter plus the appropriate service code (99201-99215), Lander says.

Details: Code 99051 is for keeping an office open, says Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn. "If you incur an extra cost in keeping staff there, you can use 99051." Consider using the code for visits during:

• evening office hours

• Saturdays and Sundays.

Choose 99050 Vs. 99051 Based on Status

Case 3: On Independence Day your office closes, but you see an established 6-month-old patient who has repeated vomiting after nursing lasting three days, cough, runny nose, and high fever.

You diagnose bronchiolitis (466.19, Acute bronchiolitis due to other infectious organisms), order an inhalation treatment that the patient responds to (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and instruct the parent on rental and use of an at-home device (94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Answer: Although this encounter occurs on a holiday, making 99051 a possible contender, you should use 99050 (plus the office visit code and procedures). Why? The office was closed.

Don't choose 99050 and 99051 based on the day. You could previously look at the day you provided the service and choose that code, Lander says. "But the Sunday code is gone."

Instead: Look at the office/clinic's operational status or hours. Anytime the office is closed and you have to come back to open it, 99050 is the way to go, Lander says. For seeing a patient on a holiday when an office is open, 99051 applies.

Apply This Code to Saturday Call-in Policy

Case 4: Your office is open on Saturday mornings for call-ins only. You don't regularly schedule appointments during these hours. What code could you assign if a pediatrician does see a patient?

Answer: Code 99051. Because you have nurses and staff already there, 99051 is the appropriate add-on code, Bradley says.

Think 99058 for 'Excuse Me, Doctor' Cases

Case 5: A parent calls in with a 1-year-old who is making grunting sounds and having trouble breathing. The triage nurse identifies the situation as emergent and advises the mother to bring the child in immediately. When they arrive, you stop your scheduled appointment to see the patient. 

Answer: Use the emergency code 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service),  Lander says. This code is appropriate when a patient comes into the office with a problem that needs immediate attention requiring you to disrupt your schedule.

Caution: Don't report 99058 for all walk-ins that you work into the schedule, Bradley says. For instance, you shouldn't use the code every time a patient has a fever that requires a same-day appointment. Think 99058 when a staff member has to stop you in the middle of a visit and say, "Excuse me, doctor. I need you in room 4."

If an emergency requires you to provide services out of the office, you could use 99060 (Service[s] provided on an emergency basis, out of the office, which disrupts other scheduled office services, in addition to basic service).

Use Late-Night Code in ED

Case 6: A patient presents to the emergency department (ED) at 2 a.m. Because the patient refuses to allow the ED physician to examine her, the doctor requests that you come in to treat your own patient.

Answer: You can report late-night facility special service code 99053 (Service[s] provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service). Medicaid and some private payers are paying for this code, said Caral Edelberg, CPC, CCS-P, CHC, in "Advanced ED Compliance Coding Essentials--Physician" at the 2007 American Academy of Professional Coder's National Conference in Seattle.