Pediatric Coding Alert

Pediatricians are often called to the emergency room to see patients. They can spend an extensive amount of time there, and then end up admitting the patient. I am having problems coding a three-hour ER visit, and then theres the history and physical which can require up to another hour, explains Vicky Slaughter, office manager for Eden Pediatrics, a two-pediatrician practice in Eden, NC. Can all of this be billed?

The answer is no, you cant bill for all of these services. You are going to have to use one of the initial hospital care codes (99221, 99222, or 99223) to admit the patient, explains Becky Miller, office manager for Childrens Clinic, a five-pediatrician practice in Tallahassee, FL. Two of our doctors are pediatric endocrinologists, so they have to go to the ER and admit a lot of diabetics, explains Miller.

But you cant bill for the time spent in the ER in addition to the hospital admit. Thats because the initial hospital care code includes any care which is provided elsewhere on that datewhether its the emergency room, the office, or elsewhere. According to CPT: When the patient is admitted to the hospital as an inpatient in the course of an encounter in another site of service (e.g., hospital emergency department, observation status in a hospital, physicians office, nursing facility), all evaluation and management services provided by that physician in conjunction with that admission are considered part of the initial hospital care when performed on the same date as the admission.

However, you canand shouldconsider the work you did in the emergency room when you are determining which level code to use for the admission. Again, from CPT: The inpatient care level of service reported by the admitting physician should include the services related to the admission he/she provided in the other sites of service as well as in the inpatient setting.

Using CPT 99223

There are a variety of situations in which a pediatrician may spend an extensive amount of time with a child in the emergency room. Say a child from out of town is in the ER with new-onset diabetes. The pediatrician spends one hour face-to-face in the ER, knowing that hell have to the admit the child. He should definitely charge a 99223, the office manager says.

Which code you use depends partly on what is wrong with the child, adds Miller. 99223, the third and highest level initial hospital care code, requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. The time guideline in CPT is 70 minutes at the bedside and on the patients hospital floor or unit.

All hospital admissions require a comprehensive level of exam and history, so the decision of which to use comes down to medical decision-making. There are three elements to medical decision-making:

Mortality and morbidity. What is the probability that the child will die or suffer injury if not treated?

Diagnosis and management options considered. How complex is the differential diagnosis? How many possible treatment options are there?

Record and tests reviewed. Did you review the past record? How many categories of tests were ordered?
To use 99223, two of the three above criteria must be complex. Here is an example from CPT: 3-year-old female with 46-hour history of sore throat and high fever, now with sudden onset of lethargy, irritability, photophobia, and nuchal rigidity.

The other two initial hospital care codes are 99222 and 99221. (See box in the next column for definition of these codes.)

Time is used to choose the level of service when the time spent counseling the patient comprises more than 50 percent of the encounter. For hospital services, time at the bedside and time on the floor in regard to the patient are both counted. This includes coordinating care, reviewing tests, and completing the medical record.

Use Prolonged Services and Consult Codes

One way to bill the three hours spent in the emergency room and then admitting the patient would be 99223 to cover the first 70 minutes, 99356 (prolonged services in the hospital) for the next 60 minutes, and two units of 99357 to cover the next 60 minutes.

What about consults? Nancy Flynn, office manager for North Country Pediatrics, a two-pediatrician practice in Littleton, NH, uses consultation codes (99241-99245) if the ER doctor calls the pediatrician in to the see the patient.

Note: You should use the outpatient consultation codes if consulting in the emergency room, prior to the admission.

But we dont always get reimbursed, she says. If the patient is admitted, and you had to choose between a consult and an initial hospital care code, it would be better to the use the hospital care code, Flynn notes. It pays better than the consultation codes.

Tip: If the patient is discharged from the ER, then you should use the outpatient consultation codes. If the patient is admitted, you would use the hospital admission codes.