Pediatric Coding Alert

Its not unusual in pediatrics for an infant or child to come in in the morning with a problem and return later in the afternoon or evening with the same problem, which has become exacerbated, or perhaps with an entirely different problem. What is the best way to code for such visits?

First of all, you can only use one Evaluation and Management (E/M) Services code per day, unless you do something entirely different on the second visit. This means that you had better choose that one code very wisely. Even if you see a child three times in one day, and end up admitting him or her to the hospital, you can only use one E/M code and, in this case, that would be the hospital admission code (99221-99223), says A.D. Jacobson, MD, FAAP, of Pediatric Associates in Phoenix, AZ, and editor of Coding for Pediatrics, published by the American Academy of Pediatrics (AAP). But, if you see the child three times in one day, you could justify using a higher-level hospital admission code than you would if you hadnt seen the child in the office once or twice earlier that day.

The basic rule to follow is this: Use a higher level code if you see a child more than once in a daybut use it only once. However, in order to support this code, you must do more work (i.e., the level of decision-making must be more difficult) and you must be sure to document carefully to support the higher level. (See page 27 for tips on how to pick the appropriate level of service.)

Multiple Diagnoses

Jacobson has found that asthma is the most common condition in pediatrics that results in multiple visits on a single day. Maybe its a level three office visit (99213) the first time you see the child with a diagnosis code of extrinsic asthma (493.0), he says. Then they go home, but return in the afternoon with acute distress. For the second visit, you would use the fifth digit on the ICD9 Codes, indicating status asthmaticus (493.01). The second office visit would be coded either a fourth or a fifth level office visit (99214 or 99215), says Jacobson, depending on how much work you did for both.

The first superbill should be disregarded altogether; just move the diagnosis of 493.00 to the list on the second visits superbill, explains Jacobson. This means you would have extrinsic asthma without status asthmaticus (493.00) and extrinsic asthma with status asthmaticus (493.01) on the same claim form attached to the level four or five office visit. Remember, its the number of diagnoses that really ups the E/M level, says Jacobson. Thats what makes your medical decision-making complicated.

In fact, the more different diagnoses you have, the more likely you will be able to use a higher E/M code, adds the physician. If there are two totally different diagnosesone in the morning and one in the eveningthat would lend itself to a higher level, says Jacobson. Anytime you have multiple diagnoses, you have a more complicated problem, which increases the difficulty of your decision-making. Medical decision-making is a key determining factor in the level, Jacobson explains.

Modifier -25

Remember that modifier -25 is defined by CPT as being for a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. However, there is no longer a requirement that the diagnosis for each service be different. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided, CPT states. As such, different diagnoses are not required for reporting of the E/M services on the same date.

Nevertheless, when using modifier -25 for two office visits on the same day, Garnet Dunston, CPC, MPC, corporate coding specialist for Managed Care Solutions of Phoenix, AZ, cautions that the service provided better be different. If, for example, the child had a cough in the morning and mild diarrhea in the afternoon, she doesnt think most carriers would pay for both office visits, any more than they would pay for two E/M codes with a modifier -25 if you saw the child for both problems at the same time. At the very least, they would delay payment. So, when you get into this kind of a gray area, you are better off using a higher-level office-visit code, says Dunston.

What if the problem was asthma in the morning, and a laceration in the afternoon? Then youd use the laceration repair code, so you might not have two E/M services codes, says Dunston. But you should still put the modifier -25 on the asthma visit, she says. This is the kind of service which would definitely qualify for a modifier -25, she adds.

Time Isnt a Factor

Its easy to think that if you spend 20 minutes with a child in the morning and another 20 minutes with the same child in the evening, you should get paid more than if you only saw that child for one 20-minute visit. But determining the level of E/M service is not based on time, unless 50 percent or more of the visit time is spent on counseling the child, the parent, or both. Otherwise, time is simply not a factor in determining the level, says Dunston. And you have to document the time spent, she notes. For example, you need to record the total time for each face-to-face encounter with the patients by the pediatricians.

Note: You dont need to record a time-in/time-out total for each visit; that is only for the critical care codes.

Concerned Mothers

Sometimes the reason for the second visit is that the mother is concerned. Perhaps the baby is having a first ear infection and a first cold. The pediatrician prescribes antibiotics in the morning, but by late afternoon, the mother is calling asking to bring the baby in because he is still not better. The pediatrician provides some reassurance, but doesnt really do a lot more work or extra decision-making. How should these two visits be coded?

The answer, says Dunston, is that you still can add up the two visits for a higher level than either would call for on its own. Maybe the first visit was a level two, and the second visit was just a level one, says Dunston. You could still make the one visit for the day a level threeif the documentation supported such a code.

But, Charles M. Vanchiere, MD, FAAP, CEO of Childrens Clinic of Southwest Louisiana, doesnt always agree with Dunston. What if the morning visit is a level three, and the afternoon or evening visit consists of nothing much beyond providing reassurance? Vanchiere says you may not be able to upcode the original visit. If you dont do anything more in the afternoon, you really cant file a higher level code, he opines. Not every visit has to be a financial encounter.

But, Vanchiere stresses that it is important to see the mother and child for that reassurance visit anyway. It affords an opportunity for educating the mother and developing a relationship with the child, he says. Also, its good marketingit shows that youre willing to see the child and the mother again.