Pediatric Coding Alert

Then see below to check your answers.

Most pediatric practices would agree that E/M codes are the bread and butter visits of the office, billed multiple times per day at nearly every level. If you consider yourself an E/M coding ace—or if you’re just getting started trying to differentiate between 99212 and 99213—you should probably check your skills. Take the following quiz, and then read below to determine whether you answered properly.

Question 1: Does High-Risk Warrant High-Level?

Question: I saw a 16 year-old patient with an established diagnosis of syncope that our physician originally diagnosed a year ago. The patient requires a release so he can get a driver’s license. The patient is doing well, and I didn’t review or order any further testing. I also addressed a concussion that the patient mentioned during the history portion of the exam. He told me a sports medicine physician diagnosed the concussion four weeks ago and he is being followed by that physician for the condition. I signed the release forms for driving and I wanted to charge a 99214, but my coder said she only sees documentation for 99213. Obviously, this is a high-risk visit. Can you advise?

Question 2: Know How to Bill for Multiple Sites

Question: Our pediatrician saw a patient in the office, then admitted her to the hospital later the same day. Can we bill for the office visit and the first day of admission, or do we just bill for the hospital stay?

Question 3: Nurse’s Time Is Valuable

Question: How do we get paid for nurse time if our nurse is just weighing a premature baby and answering the mother’s questions?

Read on for These Expert Answers

Answer 1: Does High-Risk Warrant High-Level?

Although certifying this patient to drive, considering his history, does sound like a high-risk visit, if your documentation doesn’t support the 99214, then you have no choice but to report the lower level code.

The only way you could report a 99214, in absence of the appropriate key element documentation, would be if you qualify to bill based on time. This would require you to have spent 25 minutes with the patient, at least half of which involved counseling or coordinating care. This would have to be documented in the record. For instance, “I saw the patient for 25 minutes, and spent 15 minutes advising him of safe driving techniques and the warning signs of a syncopal event so he knows when it’s unsafe to drive.”

Based on the information provided, however, this visit should be coded with 99213.

Answer 2: Know How to Bill for Multiple Sites

The answer depends on whether the physician sees the patient on the same day in the hospital.

Scenario 1: If the physician sees the patient in the hospital on the same day he saw her in the office, you’re looking at two face-to-face visits on the same date coded as one initial hospital visit. Report only the appropriate initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...). According to CPT coding guidelines, all initial hospital care services that begin in another place of location (such as the physician’s office) should be combined and coded using the appropriate level of initial hospital care.

Since the 99221-99223 code will include the E/M provided in the office, you’ll report an initial hospital care code that includes the work done in both sites of service; this typically leads to coding a higher level of initial hospital care than if you were considering the hospital services alone.

If, however, the admitting physician did not see the patient face to face in the hospital setting on the admission day, his coding would all be office visit coding that day. Initial hospital coding would be billed the next day, when the patient is seen face to face in the hospital setting for the first time. This results in a disconnect from the hospital admit and physician initial hospital coding dates. However, it makes it easier to capture all the office work provided to these ill patients.

Scenario 2: If, however, the physician does not see the patient face-to-face in the hospital until the next day, bill each encounter separately. Choose the appropriate office visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...) or 99212-99215(Office or other outpatient visit for the evaluation and management of an established patient ...) for the office visit on day one. Then add an initial hospital care code from 99221-99223 for day two, when the physician sees the patient face-to-face in the hospital for the first time.

Remember that CPT uses initial hospital care codes to describe the first hospital inpatient encounter by the admitting physician. After that, you’ll report subsequent hospital care codes, 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient . . .), until the date of discharge. When the physician discharges the patient, you’ll submit the appropriate hospital discharge day code, 99238 or 99239.

Answer 3: Nurse’s Time Is Valuable

You can capture nurse time by using a level-one office visit code (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). This code is specifically designed for services that may or may not require the skill and expertise of a pediatrician.

Code 99211 differs from the other office visit codes in two ways. First, code 99211 is included in the established patient office visit series (99211-99215) only. The new patient office visit codes (99201-99205) do not offer a similar nonphysician code. To report the nurse’s time, the pediatrician must have previously seen the patient.

Second, unlike the other office visit codes that require history, examination and medical decision-making, a level-one office visit does not require these three elements. So, to prove medical necessity for the nurse visit, E/M documentation should include:

• the complaint
• the assessment
• advice given
• the diagnosis.

For a nurse visit, typical complaints include infant spitting or concerns about weight gain. The nurse must take an assessment, such as checking the vitals, listening to the lungs, or a weight check. Record the progress of any weight gain or loss, such as “weight 10-6, up 6 ounces in one week.”

The nurse should also document any advice that she offers to the patient. The nurse may note that she recommended small frequent feeds, propping the baby up after feeds, or that she reassured the mother that the spitting was normal.

Link the E/M code to the diagnosis. Possible diagnoses include feeding problems in newborn (779.3), feeding difficulties and mismanagement (783.3). Remember that 99211 usually triggers a copayment, and families should be made aware of this.