Pediatric Coding Alert

3 steps boost your nephrology dollars'

Pediatricians who perform dialysis services aren't receiving the reimbursement they deserve when they admit their patients to the hospital. But with a few pediatric nephrology tips, you can improve your practice's pay.

1. Switch to 90923 for Per-Day ESRD Services

From a coding and billing standpoint, pediatric nephrology is one of the most problematic subspecialties that there is, says Sandra Watkins, director of pediatric dialysis and co-director of the pediatric clinical research center at the University of Washington Medical School in Seattle. It can be especially difficult for primary care providers such as pediatricians who aren't used to the monthly capitated fees for dialysis services.
 
Although the monthly codes for outpatient end stage renal disease management (90918-90921), don't present problems to pediatric coders, pediatric dialysis patients are admitted to hospitals on a regular basis and that, Watkins says, is when pediatricians lose out on reimbursement.
 
You should report monthly codes such as 90918-90921 (End stage renal disease [ESRD] related services per full month ...) once per month only to describe full and consecutive months of service. So, if an 11-year-old patient begins outpatient ESRD related services on Nov. 1, but her pediatrician admits her to the hospital on Nov. 30, you shouldn't use 90919 (... for patients between two and eleven years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents).
 
For ESRD services lasting less than one month, you should switch to daily codes (90922-90925, End stage renal disease related services ... per day ...). For instance for outpatient services from Nov. 1-Nov. 29, you should report 90923 (... for patients between two and eleven years of age) 29 times - once for each day the pediatrician treated the patient as an outpatient. Even if pediatrician admits and discharges the patient on the same day (99234-99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), you shouldn't use the monthly ESRD codes.

2. Report Dialysis and Unrelated Admission Work

"When a chronic pediatric patient comes into the hospital, you have to change the way that you are coding," says Barbara Fivush, chief of pediatric nephrology at Johns Hopkins School of Medicine in Baltimore, Md., "and (pediatricians) do badly when we have to switch to the acute codes." It's not that the acute (or inpatient) dialysis codes (90935-90937) are so confusing, it's just that you may not know how to combine them with other E/M codes.
 
Pediatric coders lose a lot of reimbursement when they first admit (99221-99223, Initial hospital care, per day, for a patient ...) patients to the hospital, Fivush says. "You can bill for an admission on the same day that you bill for dialysis (90935-90937)," she says. "People don't know that, and they bill just for the dialysis or just for the admission - but you can get paid for both."
 
When billing for a same-day admit and dialysis, make sure 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 E/M code (99221-99223). The modifier indicates that you are reporting E/M services that are unrelated to the dialysis procedure.

3. Document Well to Get to 90937

For inpatient hemodialysis services, pediatricians can do themselves a big favor by understanding the difference between 90935 (Hemodialysis procedure with single physician evaluation) and 90937 (Hemodialysis procedure requiring repeated evaluation[s] with or without substantial revision of dialysis prescription). "I don't think pediatricians are really aware of the significant difference in reimbursement," Fivush laments. In many cases, the pediatrician makes more than one evaluation of the patient, but because she doesn't make a substantial change to the dialysis, she doesn't record those subsequent evaluations.
 
Fivush counsels coders to remind their doctors to document every visit to a dialysis patient. "The doctor can be in the unit and all you have to do is write a note that two or three times, 30 minutes apart, saying that he made a change - that he changed the blood flow or did anything. That will allow you to use the more extensive code."
 If the patient is stable and the pediatrician knows her well - say the physician admits a long-time dialysis patient to the hospital for a broken leg - then the higher code may not be appropriate. But more often than not, pediatric ESRD patients will need some sort of repeated evaluation. "For those patients we should document well and use those more extensive codes," Fivush says.
 
The same principle applies to pediatric patients who undergo peritoneal dialysis. Remember to switch to codes 90945 (Dialysis procedure other than hemodialysis [e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies], with single physician evaluation) and 90947 (Dialysis procedure other than hemodialysis [e.g., peritoneal dialysis, hemofiltration, or other continuous renal replacement therapies] requiring repeated physician evaluations, with or without substantial revision of dialysis prescription).