Pediatric Coding Alert

How should you handle billing when a child is admitted by a resident, but not seen by the pediatrician until the next day? This situation has come up several times at Childrens Community Care, a 65-pediatrician MSO, based in Pittsburgh PA.

Heres the scenario: The child is admitted in the evening to the observation unit by a resident. The next morning, the childs pediatrician does rounds. He or she reviews the residents examination and documentation, and co-signs it. Then, the pediatrician does his own complete exam, reviewing any lab results and other diagnostic tests. The pediatrician writes a treatment plan and, if the child is well enough to be discharged that day, a discharge plan. The question, says Janet Klemash, ART, reimbursement specialist for Childrens Community Care, is whether the pediatrician can bill for the residents services done on the previous evening. Can the pediatrician only bill for the hands-on morning services he provided? Or can he bill for both days?

The pediatrician cannot bill for both days, says Richard H. Tuck, MD, FAAP, a regional coding resource for the American Academy of Pediatrics (AAP). A physician cannot bill a CPT code or charge for a service that he doesnt furnish on that day, says Tuck, who practices in Zanesville, OH. He can only charge for the day that he sees the patient.

This situation is similar to an emergency department (ED) physician admitting a child, says Tuck. This is a very common occurrence in pediatrics. The pediatrician may feel involved, because he or she has spoken with the family and the ED physician. And, indeed, the pediatrician is the admitting doctor, but cant bill unless he or she sees the patient. So the pediatrician cannot bill until the second day. Although attending pediatricians feel that they have decision-making responsibilities and liabilities, they cant charge until the day they see a patient, says Tuck.

Recommended Solution: Codes 99234-99236

However, there is a way to maximize reimbursement using the observation codes in this situation. If the child is seen and discharged the next day, the attending pediatrician could use same-day admission and discharge codes (99234-99236), says Tuck. The observation codes are divided into three main sections: discharge services (CPT 99217 ), initial observation care (99218-99220), and observation or inpatient care services, including admission and discharge services (99234-99236). The pediatrician could use the same day admission and discharge code, even though the child was admitted to observation the day before, says Tuck. For physicians, observation codes are based on the date the service is furnished. The same-day observation codes focus on the physicians date of service (i.e., the child is seen by the pediatrician for both admission and discharge on the same observation day) and not on the patient hours in the hospital. Since the pediatrician did not see the child on the day the child was admitted, the same-day admission and discharge codes could be used, says Tuck.