Pediatric Coding Alert

Same-day inpatient E/Ms are perfect opportunity to use revised code +99356.To avoid landing your prolonged services coding claims on the denial stack, you've got to apply these new guidelines starting Jan. 1.#1: Include Up to 29 Min Extra in E/MIf you were one of the lucky few getting paid for 99215-21 (Office or other outpatient visit for the evaluation and management of an established patient ... Prolonged evaluation and management services), CPT 2009 will disappoint you. 2008 way: "If the time documented did not exceed 30 minutes above the CPT allotted time," you could append modifier 21 to the highest level E/M code in a category, says Lynn A. Brown, CPC, director of physician coding and reimbursement at CHS in Birmingham, Ala.New method: Because the reporting and use of the prolonged service guidelines make modifier 21 obsolete, the AMA deleted modifier 21. "Prolonged service of less than 30 minutes total duration on a given date is not separately reported because the work involved is included in the total work of the evaluation and management codes," according to new CPT notes for 99354 and 99356. Loss of payment from the less than 30-minute time however, will probably not be widespread. Payers in some areas do not recognize modifier 21, Brown notes.#2: Go Straight to +99354-+99357CPT 2009 eliminates incorrectly adding modifier 21 onto a 99214 or 99222 (Initial hospital care, per day, for the evaluation and management of a patient ...) that took longer than usual by directing you instead to the prolonged services codes. "Providers and billers would forget that modifier 21 was allowed only for the highest level E/M code in a category," Brown recalls. Using a +99354-+99357 code, rather than modifier 21, provides more description. "The prolonged E/M service codes clarify whether it was face-to-face time with the patient and specify exactly the time parameters involved," explains Jennifer Swindle, RHIT, CCS-P, CPC-EM-FP, CCP, director of coding compliance/charge entry for QLIMG, and director of the coding and compliance division of PivotHealth LLC in Garden City, N.Y. Example: A visit, in which the E/M medical necessity level meets the criteria for 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity ... Usually, the presenting problem[s] are of moderate to high severity. Physicians typically spend 25 minutes face-to-face with the patient and/or family), takes 60 minutes of face-to-face time with the physician. This visit would be eligible for an additional prolonged service code of +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service; [...]