Pediatric Coding Alert

The most commonly used pediatric codes are E/M services, and when pediatricians lose money for extra time spent on these services, the loss can be big. Because the E/M codes are not age-specific, there is no easy way to reflect the excessive time young patients can consume. But there are coding solutions to this problem.

Prolonged Services

 
Outpatient prolonged services codes (99354-99355) are used in addition to an office visit code when the pediatrician provides face-to-face patient services. The time attributed to these codes need not be continuous but must be the same day as the E/M encounter. Because these codes require that time be monitored carefully, document "time in" whenever seeing a patient whose encounter might be protracted, e.g., a patient who is wheezing.
 
The descriptor for CPT 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service) specifies first hour of prolonged services, but this is misleading. Rather, this code is for 30 to 74 minutes of prolonged services -- less than 30 minutes is part of the base E/M service.
 
Use the time indicator in CPT Codes for the office visit to calculate when to start the clock for prolonged services. For example, an infant needs treatment for bronchiolitis. He is in an exam room -- receiving nebulizer treatments and being monitored for respiratory function -- for a total of 120 minutes, 85 of which the pediatrician is in constant attendance. Bill 99215 (office or other outpatient visit for the evaluation and management of an established patient) for the office visit and 99354 for prolonged services. The time indicator for 99215 is 40 minutes face-to-face. The total time spent on the encounter was 85 minutes, so 45 minutes qualifies for prolonged services.
 
If a total of 65 minutes had been spent, 99215 should be reported alone because only 25 extra minutes were required -- not enough to bill prolonged services.
 
Documentation Issues 

 
When providing documentation for prolonged services, take care to track not only the time but the services provided, says A.D. Jacobson, MD, FAAP, chairman of the AAP Section on Administration and Practice Management and a practicing pediatrician in Phoenix. "Document how long you spend with the patient in the chart, and note exactly what you do during that time," he says.
 
The pediatrician need not be in constant attendance to bill the prolonged services codes, Jacobson says: "You might leave the room to see a child with an earache, or another kind of brief visit." But track the time in and out so you are not double-dipping by billing prolonged services for one patient during the time you are seeing a different patient.
 
Some pediatricians don't like to bill for prolonged services because they feel they're not with the child on a continuous basis. "But remember that you're tying up one of your rooms and probably a nurse as well," Jacobson says.

Upcoding for Counseling

 
Time spent talking to parents is one reason pediatricians are so concerned about how to bill for their time. The solution is upcoding. If more than 50 percent of the encounter time is spent on counseling or coordination of care, the pediatrician can upcode the visit based on time.
 
Use the time indicators in CPT to upcode for time spent on counseling or coordination of care:
 
New patient visits:
 
99201 -- 10 minutes
 
99202 -- 20 minutes
 
99203 -- 30 minutes
 
99204 -- 45 minutes
 
99205 -- 60 minutes.
 
Established patient visits:
 
99212 -- 10 minutes
 
99213 -- 15 minutes
 
99214 -- 25 minutes
 
99215 -- 40 minutes.

 
For example, the pediatrician sees an 8-year-old with ADHD for a prescription refill, and the mother also wants to discuss behavior problems. The visit would warrant 99213 based on the three elements of history, examination and medical decision-making. But after spending 10 minutes with the child, the doctor spends another 30 minutes talking to the mother. Because more than 50 percent of the time is spent on counseling, amounting to a total of 40 minutes, 99215 is warranted. Document minutes of visit time with a "V" and minutes of counseling time with a "C," i.e., 10V/30C.
 
In another example, a mother brings in her 15-year-old daughter because of concerns about smoking. The pediatrician examines the girl and talks to her and the mother about the hazards of smoking. The physician must also discuss the situation with the guidance counselor at school later in the day. A total of 15 minutes is spent on counseling the girl and parent, and five minutes on discussing the case with the guidance counselor. The office visit takes 10 minutes. The E/M codes cannot be used because the counseling was not face-to-face.
 
Remember that time cannot be used as a factor unless more than half of the total face-to-face encounter time is spent on counseling and coordination of care.

Modifier -21

 
When a level-five code is warranted before time is taken into account, but additional time is required (i.e., a case is so severe that the pediatrician would bill 99205 or 99215, but there is a lot of time spent counseling in addition), modifier -21 (prolonged evaluation and management services) may be used. This modifier may be appended only to level-five E/M codes. The expected increase in charges is about 40 percent.
 
"Modifier -21 is an appropriate modifier when the service is prolonged," says Garnet Dunston, CPC, MPC, a pediatric coding expert who owns Dunston Enterprises in Phoenix. She says there are some clearly justifiable cases for the use of modifier -21.
 
For example, a 2-year-old presents with what appears to be her third case of bronchiolitis since birth. After the pediatrician treats the acute condition with nebulizers, he talks with the mother about environmental issues -- household pets, family allergies and so on -- and the possibility of asthma. The mother strongly resists the diagnosis, and the pediatrician carefully explains his reasoning and the need for continued home monitoring and treatment. The visit warrants a 99215, but the pediatrician also spends 45 minutes discussing the situation with the parent, so modifier -21 should be appended.
 
Consider these other examples of modifier -21 use:
 
1. During a difficult divorce, a father brings in a 3-year-old child with concerns about sexual abuse. "Those circumstances take extra time," Tuck says.
 
2. A sexually active teen-ager with abdominal pain and concerns about sexually transmitted diseases and pregnancy asks the physician for advice and opinions.

 
Some coders view modifier -21 as too "subjective" and prefer to access prolonged services when possible, Tuck says.