Pediatric Coding Alert

Ever since colonial times, when babies were born at home and sick children remained there under a physician's care, pediatricians have routinely made house calls.
Reimbursement has rarely been adequate for such services, though. Furthermore, pediatricians nowadays are just too busy. You cant be expected to see five patients in an hour if you have to travel to them. Also, it is easier to take care of most patients in your office or the hospital.

But there can be a place for house calls -- now called home visits. And the service has finally been given the imprimatur of a full range of Evaluation and Management (E/M) codes. Until this year, there were inadequate home-visit codes for higher level cases, those involving complex chronic care. However, this year several home-visit codes that were introduced five years ago have been reviewed, and made more appropriate for pediatrics. The original codes were meant for homebound elderly with chronic diseases. The 1998 codes were revised with input for realistic pediatric home health situations; in addition, new codes have been added. For complex chronic care (special-needs children), pediatricians can use these codes and their reimbursement has the potential to increase by 50 percent over the 1997 codes.

Reimbursement and Home Care

With home care until now used mainly for geriatric patients, there was little relevance for pediatricians. There used to be no way to get good reimbursement for home visits, says Allen I. Goldberg, MD, FAAP, director of pediatric home health at the Ronald McDonald Childrens Hospital at Loyola University Medical Center in Maywood, IL. There werent enough codes for pediatricians, he says.

All that has changed. Goldberg, who is also the founder of the AAPs section on home health care, says the field has opened up considerably for pediatrics. The first move occurred when a care-oversight code was added (more about that code coming in the April 1998 issue of PCA). Last year, when Medicare overhauled its home-visit codes, Goldberg was ready to make sure pediatricians voices were heard. We came up with some pediatric scenarios to utilize the codes, he explains. The scenarios were written by Goldberg with input from other members in the AAP's section on home health.

The relative values were also upgraded. And now, pediatricians can take care of a complex child with special-care needs at home and have the potential to be adequately reimbursed, says Goldberg. The home-services codes fit in with what managed care wants too: it is less expensive to provide care at the patient's home than in the hospital.
Here are the revised as well as new home-services codes, plus sample scenarios applying to their pediatric use:

99341 (revised code): New patient requiring a problem-focused history, problem-focused examination, and straightforward medical decision-making. The problem or problems are usually of low severity. The pediatrician would typically spend 20 minutes with the patient and/or family.

Example: 9-year-old male new patient referred to home care with severe spastic cerebral palsy. Requires renewal of seizure medication. No recent change in seizure incidence but his physician will not refill his prescription over the phone, not having seen the patient for two years. Specialty transport to office logistically difficult.

99342 (revised code): New patient requiring an expanded problem-focused history, and expanded problem-focused examination, and medical decision-making of low complexity. Usually the presenting problems are of moderate severity. The pediatrician would typically spend 30 minutes with the patient and/or family.

Example: 14-year-old female new patient who is a wheelchair-dependent quadriplegic at home for several years after an automobile accident. Currently normotensive with rare mass reflexes. Previous physician managed autonomic nervous system instability and frequent mass reflex responses at home. You are being asked to assume her care.

99343 (revised code): New patient requiring a detailed history, a detailed examination, and medical decision-making of moderate complexity. Usually, the presenting problems are of moderate to high severity. The pediatrician would typically spend 45 minutes with the patient and/or family.

Example: 12-year-old female new patient who has had three acute hospitalizations in the past 6 months for status asthmaticus despite office visits and active home health agency nursing care. She has chronic wheezing despite home aerosol therapy and high-dose oral steroids. She has significant school absenteeism and the pediatrician has been asked to evaluate the patient in her home environment and call school authorities with recommendations.

99344 (new code): New patient requiring a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Usually, the presenting problems are of high severity. The pediatrician would typically spend 60 minutes with the patient and/or family.

Example: 8-month-old male infant new patient at home with bronchopulmonary dysplasia requiring long-term oxygen and cardiopulmonary monitoring. Actively followed by home health nurse who calls physician for evaluation of poor growth, increasing incidence of intermittent wheezing, and more frequent oxygen de-saturating during nipple feeding over past few months. Parents have been up many nights and are emotionally exhausted.

99345 (new code): New patient requiring a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Usually, the patient is unstable or has developed a significant new problem. The pediatrician would typically spend 75 minutes with the patient and/or family.

Example: 12-year-old female new patient at home with chronic respiratory insufficiency due to neuromuscular weakness from myopathy requiring prolonged mechanical ventilation and long-term oxygen. One-day history of severe vomiting and diarrhea and reduced oral intake. Parents very capable of home care and want to avoid hospitalization. They call physician due to significantly reduced urine output. Request home evaluation for hydration status but regular physician on vacation.

99347 (new code): An established patient requiring at least two of the following: a problem-focused interval history, a problem-focused examination, and straightforward medical decision-making. Usually, the problems are self-limited or minor. The pediatrician typically would spend 15 minutes with the patient and/or family.

Example: 8-year-old male established patient with severe developmental disability with frequent pneumonia requiring hospitalization and being considered for long-term oral antibiotic management. Patient becomes extremely agitated during office visits but can be easily evaluated by physician while at play on the floor at home.

99348 (new code): An established patient requiring at least two of the following: an expanded problem-focused interval history, an expanded problem-focused examination, and medical decision-making of low complexity. The problems are usually of low to moderate severity. The pediatrician would typically spend 25 minutes with the patient and/or family.

Example: 9-month-old female established patient at home on parenteral nutrition due to short bowel syndrome resulting from bowel resection required for necrotizing enterocolitis as newborn. Despite frequent home health agency visits, has had poor growth and parents are discouraged and exhausted due to recent increased irritability. Home health agency nurse requests home visits for evaluation of nutrition status, management, and parent counseling.

99349 (new code): An established patient requiring at least two of the following: a detailed interval history, detailed examination, and medical decision-making of moderate complexity. The problems are usually of moderate to high severity. The pediatrician would typically spend 40 minutes with the patient and/or family.

Example: 4-year-old female established patient at home on long-term oxygen and prolonged mechanical ventilation ever since birth due to restrictive lung disease (chest wall deformities surgically corrected as a neonate) and severe residual bronchopulmonary dysplasia. Requires 24-hour private duty nursing since both parents work full time with frequent overtime. Physician visit at home with entire home care team (nurses, therapists, parents, and representatives from school, nursing agency, and DME) required to reevaluate home care plan based on medical necessity.

99350 (new code): An established patient requiring at least two of the following: a comprehensive interval history, a comprehensive examination, and medical decision-making of moderate to high complexity. Usually, the problems are of moderate to high severity. The patient may be unstable or have developed a significant new problem. The pediatrician would typically spend 60 minutes with the patient and/or family.

Example: 12-year-old male established wheelchair-bound patient, high-level spinal cord injured (C1-C2) tracheostomy and ventilator dependent in acute respiratory distress with high fever. Secretions have increased and are difficult to manage. Parents have increased suctioning, bronchopulmonary toilet, and frequency of aerosol treatments. Prefer home management but concerned that child will go into acute respiratory failure and request physician evaluation.