Pediatric Coding Alert

Sometimes a pediatrician must visit a hospitalized child more than once a day. But CPT specifically states that all hospital care codes are per day, not per visit. Mary Joyce, business manager for Westbury Pediatrics, St. Charles, MO states the problem succinctly. Is there a way to code a second inpatient hospital visit for the same day and have it reimbursed by insurance? Using a -25 modifier doesnt seem to work. It is not unusual for a pediatrician to have to make an a.m. and p.m. visit to the hospital to care for an ill child, writes Joyce.

The short answer to this question is no, there is no code for the second visit. You cant code a hospital visit to the same patient more than once in one day, says Charles M. Vanchiere, MD, FAAP, chair of the RBRVS PAC of the AAP and CEO of Childrens Clinic of SW Louisiana in Lake Charles. You have to just code for one visit.

However, you have options for what code to use, to get reimbursed more fairly. You can go up to the next code level, says Vanchiere. But you shouldnt do this automatically, just because you have visited the patient twice. Whether you decide to convert your two second-level visits to one third-level visit, for example, depends on the work you do during those two visits, the coding expert stresses. Obviously, time is something of a factor here, since you are visiting the patient two times. It can be time-related, he notes. But it should be necessary time. It cant be just because youre in the hospital anyway.
The hospital care codes are as follows. All are on a per day basis.

(Note: In the code descriptions before typical time spent applies to time spent at the bedside and on the patients hospital floor or unit.)

Initial (Admitting) Hospital Care Codes

CPT 99221 - for a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision-making that is straightforward or of low complexity. Typical time spent: 30 minutes. (Example: admission of an 18-month-old child with 10-percent dehydration.)

99222 - for a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Typical time spent: 50 minutes. (Example: admission for an 8-year-old febrile patient with chronic sinusitis and severe headache, responsive to oral antibiotics.)

99223 - for a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Typical time spent: 70 minutes. (Example: admission for a 9-year-old with vomiting, dehydration, fever, tachypnea, and an admitting diagnosis of diabetic ketoacidosis.)

Subsequent Hospital Care Codes

These include reviewing the medical record and the results of diagnostic studies and changes in the patients status since the last assessment by the pediatrician. They are as follows:

99231 - requires at least two of the following: problem-focused interval history, problem-focused examination, and medical decision-making that is straightforward or of low complexity. Typical time spent : 15 minutes. (Example: visit for a 4-year-old female, admitted for acute gastroenteritis and dehydration, requiring IV hydration, now stable.)

99232 - requires at least two of the following: expanded problem-focused interval history, expanded problem-focused examination, and medical decision-making of moderate complexity. Typical time spent: 25 minutes. Example: visit for a 20-month old male with bacterial meningitis treated one week with antibiotic therapy; has now developed a temperature of 101.0.

99233 - requires at least two of the following: a detailed interval history, a detailed examination, and medical decision-making of high complexity. Typical time spent: 35 minutes. Example: a 4-year-old female patient with diabetes was admitted the previous day with dehydration from a stomach virus; today the patient has a fever of 103 and loses control of her blood sugar levels.

Prolonged Services

Another option, which should be useful if you spend a great deal of time with the patient during at least one of those two visits -- is to use a Prolonged Services code, says Vanchiere. You should use the appropriate hospital care code, plus 99356 for the first hour of prolonged service. First hour means any amount of time from 30 to 74 minutes. Each additional 30 minutes is to be reported as 99357.

(Note: Do not confuse 99356 and 99357, which are for inpatient use, with prolonged services codes 99354 and 99355, which are for office use.)

Unlike the hospital care codes, these prolonged services codes (99356 and 99357) are for face-to-face patient contact. Non-face-to-face time should be coded 99358 for the first hour, and 99359 for each additional 30 minutes.

(Tip: Anything done on the floor with regard to the patient -- reviewing records or lab results, for example -- is included in the face-to-face code 99356. The non-face-to-face codes are not likely to be paid, and in fact have a relative value of zero.)