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Pediatric Coding Alert

Keep an Eye on Follow-Up Care When Coding Extended Hospital Stays

Published on Sat Feb 01, 2003

To report care complexity and medical decision-making accurately for pediatric and neonatal patients receiving long-term hospital care, providers should be prepared to apply critical care, subsequent care and add-on prolonged physician service codes, coding experts stress.

Patients who are long-term hospitalization candidates in pediatric facilities often include children and neonates with life-threatening illnesses, injuries or congenital anomalies who need critical care services, so pediatricians should know when to apply the new and revised critical care codes (99293-99296) listed in CPT 2003. (See the December 2002 Pediatric Coding Alert for more on these codes.)

Report 99293-99296 if patients are less than 2 years old and if they meet CPT's definition of "critical," says Shirley Fullerton, CMBS, CPC, CPC-H, academic director for the Medical Association of Billers in Las Vegas and a coder for MedQuist, a national Internet coding and transcription company based in New Jersey. In its critical care services section, CPTspecifies that "a critical illness or injury impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition." Physicians should remember that codes 99293-99296 are global and report these codes only once per day, per critical care patient, Fullerton notes.

For critically ill patients more than 2 years old, apply CPT 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) for the first 30 to 74 minutes of critical care and +99292 (... each additional 30 minutes [list separately in addition to code for primary service]) to report additional blocks of time of up to 30 minutes each beyond the first 74 minutes.

Use 99291-99292 to reflect the time the physician spends administering constant critical care to a particular critically ill or injured patient. For instance, if a pediatrician spends 40 minutes discussing the care of a critically ill burn victim with the patient's family, the physician would report 99291.

Subsequent Care Codes Reflect Therapy Response

For noncritical care patients, use the subsequent hospital care codes, depending on the level of care as reflected in the history, physical exam and medical decision-making, for services the physician provides after the initial hospital admission, says Richard Molteni, MD, FAAP, a neonatologist and member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN). The subsequent hospital care codes are:

  • 99231 Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of three key components. Usually the patient is stable, recovering or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.
  • 99232 ... Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside ...
  • 99233 ... Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside ....

    Providers should keep in mind that the level of care for subsequent hospital care codes must be supported by complete and accurate documentation, coding experts urge.

    Low Birth Weight Lengthens Inpatient Time

    Often very low and low-birth-weight infants become long-term inpatients, so pediatricians should apply the new intensive (noncritical) low-birth-weight services codes for extended hospitalizations: 99298 (Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant [present body weight less than 1500 grams]) and 99299 (... low birth weight infant [present body weight of 1500-2500 grams]). These codes recognize that little may change on a day-today basis but that the opportunity for instability or catastrophic deterioration always exists, Molteni says. Codes 99298 and 99299 are global and include the same bundled procedures as listed on page 21 of the CPT manual for 99293-99296. They are also exempt from the typical E/M documentation requirements, Molteni says.

    Once an infant's body weight is more than 2,500 grams, report the subsequent hospital visit codes, says Patricia Wildman, RHIA, clinical reimbursement auditor at Children's Hospital in Boston.

    Use Prolonged Physician Services Codes Sparingly

    Patients with chronic conditions such as cystic fibrosis (277.02) who are long-term inpatients frequently receive physician care that extends beyond the usual E/M inpatient service.

    Pediatricians should report prolonged services codes when the total duration of the prolonged services is at least 30 minutes longer than the average time of the selected E/M code, Wildman says.

    Documentation is crucial for these time-based codes, Fullerton stresses. She advises physicians to record start and stop times and to specify provided services.

    Add +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service ...; first hour [list separately in addition to code for inpatient evaluation and management service]) to the appropriate E/M code for prolonged face-to-face physician care in hospital settings and +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service]) for additional time spent face-to-face. For example, you would add 99356 to the appropriate E/M code if a pediatrician spends 40 minutes giving continuous bedside care to an acutely ill inpatient.

    Append +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care ...; first hour [list separately in addition to code(s) for other physician service(s) and/or inpatient or outpatient evaluation and management service]) to E/M codes for extra time spent in non-face-to-face activities such as chart review and +99359 (... ) for additional time spent providing non-face-to-face services.each additional 30 minutes [list separately in addition to code for prolonged physician service]

    The non-face-to-face prolonged service codes do not have any published relative value units, and providers should check with insurance carriers about reimbursement, says Jeffrey Linzer Sr., MD, MICP, FAAP, assistant professor of pediatrics at Emory University and EMS coordinator at Children's Healthcare of Atlanta and Hughes Spalding Children's Hospital.

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