Pediatric Coding Alert

Sometimes pediatricians are summoned to the emergency room because they know their patient and the family best. Or, the emergency department (ED) physician may not be experienced with children. Or, there may be some pediatric implications that the emergency physician wants some assistance with.

The biggest problem for pediatricians seems to be getting reimbursed for meeting the family in the ED, says Daniel Leviten, MD of Lakeside Pediatrics, a four-pediatrician practice in Lakeland, FL, who posed that exact question to PCA.

Leviten has hit a nerve, according to Laura Perry, coding analyst for Pediatric Surgical Associates, a six-physician group in Fort Worth, TX. We have been back and forth on this, says Perry. Our doctors are on call, but theyre not ED doctors. Formerly, when her pediatricians went to the emergency room, and the patient was not admitted, they coded an office consultation. But the place of service didnt match the code (since the visit didn't occur in their office), says Perry. So now were coding it as an ED visit (99281, 99282, 99283, 99284, 99285). Sometimes they go there to see a patient for abdominal pain, and then send the child home. The fact is, says Perry, that the reimbursement was greater for a outpatient consult. But we had to appeal every one of them (consult codes), so our office manager told her doctors to just use the ED codes, adds Perry

Perrys instincts were correct, and the insurance carriers who arent honoring the consultation codes are wrong. It doesnt matter where the pediatrician sees the patient -- emergency department or office. If the ED physician requests that you see a child there, you should use the consultation codes. The only time the pediatrician should use the ED codes is when he or she is the only physician taking care of the child -- one of those rare situations when the pediatrician says Ill meet you there and he or she is the first physician to see the patient. Otherwise, usage of the consultation codes is correct.

If, by the end of the day on which the child went to the ED, the child has been treated and discharged, you should code for an outpatient consultation (99241, 99242, 99243, 99244, or 99245). If the child is admitted that same day, you have a choice: you can code for an inpatient
consultation, or an admission.

In the adjacent column are the ED and consultation codes. Note that all of the ED codes include counseling and/or coordination of care with other providers or agencies...consistent with the nature of the problem(s) and the patients and/or familys needs.

Emergency Department Codes

CPT 99281 - requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. (Example: Uncomplicated suture removal.)

99282 - requires an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. (Example: Child presenting with impetigo localized to the face.)

99283 - requires an expanded problem-focused history, and expanded problem-focused examination, and medical decision-making of moderate complexity. (Example: Well-appearing 8-year-old with fever, diarrhea and abdominal cramps, tolerating oral fluids and not vomiting.)

99284 - requires a detailed history, a detailed examination, and medical decision-making of moderate complexity. (Example: 4-year-old child who fell off bike sustaining a head injury with brief loss of consciousness.)

99285 - requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. This code is usually used when there is an immediate significant threat to life or physiological function. The three required components are to be performed within the constraints imposed by the urgency of the patients clinical condition and mental status. (Example: Previously healthy young adult patient injured in an automobile accident and brought to the ED immobilized and has symptoms compatible with intra-abdominal injuries or multiple extremity injuries.)

Outpatient Consultation Codes

99241 - requires a problem-focused history, a problem-focused examination, and straightforward medical decision-making. The typical time spent with the patient and/or family is 15 minutes.

99242 - requires an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. The typical time spent with the patient and/or family is 30 minutes.

99243 - requires a detailed history, a detailed examination, and medical decision-making of low complexity. The typical time spent with the patient and/or family is 40 minutes.

99244 - requires a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Typical time spent with patient and/or family is 60 minutes.

99245 - requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Typical time spent with the patient and/or family is 80 minutes.