Pediatric Coding Alert

Don’t forget to keep your eyes on the clock.

With all the attention being paid to the changes being made to the office or other outpatient evaluation and management (E/M) codes this year, it’s important to remember that all the other E/M CPT^® codes will remain unchanged for the foreseeable future.

That means now is a good opportunity to review some of the other E/M codes that get frequent workouts in pediatric settings: 99221-99223/99231-99233 (Initial/ Subsequent hospital care, per day, for the evaluation and management of a patient …) and 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient …).

So, here are the answers to your frequently asked questions about the services.

Question: When Should I Use 99221-99223 or 99234-99236 for Inpatient Care?

Answer: “The basic difference between the codes is that 99234-99236 represent the services of an initial hospital service and a discharge service performed on the same calendar date,” says JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. This means your documentation must reflect the exact times for admission and discharge.

“To bill 99234-99236, you must have a statement that shows the stay for observation care or inpatient hospital care was greater than eight hours but less than 24 hours,” advises Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. “If the admission is greater than 24 hours, then you would use 99221-99223 for the initial day of hospital care,” Miller adds.

Question: When Can I Bill for Hospital Care?

Answer: Knowing which provider can, and cannot, bill these codes is a typically problematic issue with inpatient care. But one easy way to break it down is to remember that, “for the inpatient initial visits, only one physician can be the admitting physician and only the admitting physician can use codes 99221-99223. All other providers should bill the inpatient E/M codes that describe their participation in the patient’s care (i.e., subsequent hospital visit or inpatient consultation),” according to Miller.

For example, “if Provider A sees the patient in the morning and Provider B, who is covering for A, sees the same patient in the evening, the notes for both services are combined and only one subsequent hospital visit is coded. However, if two physicians see the patient and they are in different specialties and are seeing the patient for different reasons (i.e., different diagnosis), then both may bill a subsequent hospital visit based on that physician’s note and the medical necessity of the service,” Miller adds.

Question: How Should I Document Hospital Care?

Answer: First, these codes require you to document that the three key components of history, examination, and medical decision making (MDM) appropriate to their levels have been met.

Coding alert: Remember that unlike the office and outpatient E/M codes, this will not change in 2020, and you will not be able to choose the level of hospital care based on MDM alone.

Next, in addition to a statement of the total time for the care, “documentation in the medical record should include personal documentation by the billing provider indicating presence and face-to-face services were provided and admission and discharge notes written by the billing provider,” says Miller.

Additionally, “because 99234-99236 represent both observation and hospital services, the documentation should support both services. That’s why I refer to these codes as ‘the combo codes,’” Wolf adds.

Question: What Does, and What Does not, Count for Time?

Answer: Like the revised 2021 office and outpatient E/M guidelines, you also have the choice to document hospital care based on time. However, this can lead to some problems when reporting the codes. “Time is often underreported for inpatient E/M services. Providers don’t always remember to document time that is spent on the unit/floor that is outside the face-to-face time with the patient and family,” notes Wolf.

Or, per CPT^® guidelines, “unit/floor time … includes the time present on the patient's hospital unit and at the bedside rendering services for that patient. This includes the time to establish and/or review the patient's chart, examine the patient, write notes, and communicate with other professionals and the patient's family.”

Another important thing to remember here is the typical times for the codes are all very different, as the following chart shows:

Question: Can I Bill for a Related Office and Outpatient E/M in Addition to the Initial Hospital Visit?

Answer: Yes. “If the patient is seen in the office on one day and admitted on the next day by the same physician, even if less than 24 hours have elapsed, you can code both the office visit and initial hospital visit,” Miller advises.

The last word: My best advice would be to watch your admit times and place of service. Your admission times will help determine the correct CPT^® code,” says Miller.