Pediatric Coding Alert

In last months issue of PCA, we discussed how to code for treating an anaphylactic reaction to an allergy shot. In the case presented, the child required epinephrine, intravenous fluids, Benadryl, and continuous monitoring by the physician for about 50 minutes. The story dealt with the coding of the visit, and one recommendation was to use the prolonged services codes. We discussed the various permutations of codes that should be used for such a visit.

This follow-up gives an illustration of how you should calculate the prolonged services codes. Because CPT is somewhat confusing on this issue, we are covering it here.

When you bill an office visit and prolonged services, here is a good approach to take, says Thomas Kent, CMM, a pediatric practice advisor and a seminar leader for the Maryland-based consulting firm McVey Associates. Choose the office-visit level of service based solely on the complexity of medical decision-making, says Kent. If, beyond the services in the office visit, the pediatrician spends 30 minutes or more in consulting or attending to the patient, then you should bill prolonged services as well. Implicit in this is the need for documentation to show what time was spent over and above the office-visit portion.

Here is another criterion: If the pediatrician spends 10 to 20 minutes extra with a patient, you can upcode to the level of services based on time. (While time should not be used to determine what level of service to code, it does become an overriding factor when more than 50 percent of the visit is spent on counseling.) If the pediatrician spends 30 minutes or more in time on counseling, then bill the office visit as well as prolonged services, says Kent.

When computing all of this I do not assign a specific time to the office-visit portion, Kent notes. Usually, these office visits have two segments: the evaluation and management phasein which the patient is diagnosed and treatment methods are decided; and the treatment section.

So, when billing for prolonged services, there will be two distinct time segments: (1) The time spent in evaluation and management and (2) all other time. Only the second portion needs to be written explicitly, says Kent, although he adds that some auditors look for both times to be written. When I use prolonged services, the time spent in the workup (the E/M service) is not counted toward the prolonged services, he explains. This initial time segment is also not used for choosing the E/M. It just sits there out of the way. All other time spent in monitoring and counseling the patient or parent, should be used for the prolonged service.

The time does not need to be continuous, Kent stresses. If a patient comes in twice on the same day you might add the two counseling times together to support prolonged services. Here are three examples from Kent of how to use prolonged services.


Example 1: Patient is seen for acute asthma (10 minutes), treated once with nebulizer (5 minutes), counseled on the use of the inhaler (15 minutes), and sent home. (Note that the time is only for the pediatricians face-to-face time with the patient and/or parent.) Assume that the E/M code for acute asthma in this case was 99214 based on history, examination, and medical decision-making. The 5 and 15 minutes are too few to support 99354. So instead, I would upcode to 99215, says Kent.

Example 2: Patient is seen for acute asthma (10 minutes), treated three times with nebulizer (5 minutes, 5 minutes, and 5 minutes), and counseled and trained in the use of the home nebulizer by the pediatrician (15 minutes). The total time equals 30 minutes. So now I would bill the 99214 based on the E/M alone and 99354 for the prolonged services, Kent adds.

Example 3: Patient is seen in the morning for acute asthma (10 minutes), treated twice with a nebulizer (5 minutes and 5 minutes), counseled (10 minutes) and sent home. The patient returns in the afternoon again with acute asthma (8 minutes), is treated twice with nebulizers (5 minutes, 5 minutes), counseled by the pediatrician (10 minutes) and trained in the use of the home nebulizer by the nurse (15 minutes). The morning visit qualifies as a 99214, but adding the afternoon visit to this makes a 99215 (remember that you cant bill two E/M codes in the same day). The nebulizer and pediatrician counseling equal 30 minutes, so you can add 99354 to the 99215. The nurse training, says Kent, is 97535 (self-care/home management training).

While the definition of prolonged services (99354) is the first hour in any day, you can begin utilizing this code if 30 minutes or more have been used, says Kent. Although, it could be argued that any time spent over the time allotted in CPT Codes for that level visit would be prolonged services. CPT guidelines only allow you to bill 99354 after 30 minutes of prolonged time has elapsed. It is not that the first 30 minutes of the additional time does not count, he notes. In this case, Kent would upcode to the next E/M level instead of adding a prolonged services code. Or, as mentioned above, choose the E/M level of service based on medical decision-making alone, and then add prolonged services if more than 30 minutes are involved.

Critical Care Codes

In the anaphylactic-shock scenario mentioned at the beginning of this article, you could even use the critical care codes (99291-99292), notes Kent. In utilizing epinephrine and Benadryl, the pediatrician is performing life-saving procedures, he notes. Also, the pediatrician was in attendance for 50 minutes. This would qualify for 99291, says Kent. Critical care codes are based on duration: 99291 is for 30 to 74 minutes, and 99292 is added on for each additional half-hour. The time doesnt have to be continuous, but the code can only be used once on a given date.

Notes: Certain services are included in the critical care codes, and cannot be reported separately: cardiac output measurements (93561, 93562), chest x-rays (71010, 71020), blood gases, and information stored in computers (such as ECGs, blood pressures, hematologic data); gastric intubation (91105); temporary transcutaneous pacing (92953); ventilator management (94656, 94657, 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36600). Also, critical care codes can be used in any location and in combination with any other E/M services, says Kent. A modifier should not be necessary.