Pediatric Coding Alert

The Medicare Fee Schedule released Nov. 1, 2001, shows a big increase in the relative value units (RVUs) for pediatric venipuncture codes 36400 (venipuncture, under age 3 years; femoral or jugular or sagittal sinus) and 36405 ( scalp vein). It took some fighting, but thanks to Charles Schulte, MD, FAAP, and Richard Lander, MD, FAAP, a multispecialty panel agreed that the former values of .18 were too low.
 
The relative value update committee (RUC) had originally recommended .38 for 36400 and .32 for 36405; CMS disagreed. After the pediatricians presented their case, CMS agreed to new values of .38 and .31.

The new patient transport codes 99289 (physician constant attention of the critically ill or injured patient during an interfacility transport; first 30-74 minutes) and add-on +99290 ( each additional 30 minutes [list separately in addition to code for primary service]) have no RVUs at all. The American Academy of Pediatrics (AAP) requested these codes, because pediatricians must often be with a newborn who must be transferred to a facility with a neonatal intensive care unit after birth or with an older child who must be transferred to a facility with a pediatric intensive care unit. The RUC recommended RVUs of 4.8 and 2.4. However, CMS did not print any values at all and assigned G codes for Medicare purposes only.

Pulse oximetry (94760, noninvasive ear or pulse oximetry for oxygen saturation; single determination) is still on T-status, which means it will be paid only when no other service is provided that day. Pediatricians should still use 94760 when they perform pulse oximetry during an encounter, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. "Code pulse oximetry properly," she says, noting that many non-Medicare payers still cover it even when billed with E/M and other codes.

Immunization administration (90471-90474) a sore topic since the codes were first created for pediatricians has still been accorded no physician work value by CMS. "They say it's included in the preventive medicine visit," Walsh says. This is despite the fact that at some visits four or five vaccine information sheets must be given out, with possible side effects fully explained. When immunizations are administered outside of a preventive medicine service, CMS says that the work involved should be considered when determining which sick visit to code. CMS does not address the issue of diagnosis coding when administering immunizations during a sick visit.

Also to be noted is a 5.4 percent decrease in the conversion factor, from $38.26 to $36.20. This would give you $50.32 unadjusted for 99213 (office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 15 minutes face-to-face with the patient and/or family) next year, opposed to $53.18 this year.
 
Reread your managed care contracts; some contracts tie reimbursement to a specific percentage of the Medicare rates (for example, 110 percent of Medicare). The office can expect a decline in revenues from these plans in the coming year. Keep an eye on the ongoing debate; medical societies are asking for a postponement of the new conversion factor for six months.