Pediatric Coding Alert

By A.D. Jacobson, MD, FAAP

Chairman of the American Academy of Pediatrics (AAP) section on administration and practice management, A.D. Jacobson, MD, FAAP, is a full-time pediatrician as well as a coding expert. He served on the AAPs coding and reimbursement committee and is past editor of the AAPs Coding for Pediatrics. He practices with Pediatric Associates, a four-pediatrician practice in Phoenix, Ariz. These tips are the second part two of a two-part series.

There are many everyday occurrences in a pediatric practice that are rich in coding challenges and solutions. Last month in this column I reviewed some ways to think creatively about coding. This month, I deal with some more common situations, and also some specific areas in which pediatricians could code but dont.

1. Nurse visits. This code (99211) is the lowest level of established patient coding and does not require face-to-face contact with a physician. This is usually done by a nurse. Here are some examples:

Immunizations: Code CPT 99211 can be used in addition to the administration code for the vaccines, as well as for the vaccine code itself. You may need to use a -25 modifier (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service).

Note: This is a controversial area. Some coding experts say you cannot use both 99211 and the administration code for the same visit.

Positive strep test: If a patient has a positive rapid strep test, the pediatrician needs to determine before writing a prescription whether there are any allergies to antibiotics. Also, the pediatrician needs to see whether strep is a recurrent problem for the child. This must be a face-to-face encounter although it can be with the nurse.

Ritalin refills: This is a good opportunity to use 99211. Again, this must be a face-to-face encounter with the nurse. You cannot use 99211 for having a prescription written and giving it to the patient when he or she walks in.


2. Emergency add-on code. If you see a patient on an emergency basis, you can add on code 99058 (office services provided on an emergency basis) for additional reimbursement. Typical emergencies include an acute asthma attack (493.01), a febrile neonate (780.6), and a laceration. In addition, many walk-ins are emergencies.

3. Hearing screening. If you use evoked otic acoustic emission hearing screens (Audiopath), you can bill 92587 (single level) or 92588 (multiple levels and frequencies) for added reimbursement, which varies from $50 to $100. You may need to use modifier -25 on the E/M service.

4. Orthopedic procedures. There are several orthopedic procedures that are commonly performed by pediatricians. You can use the procedure code instead of an E/M service for higher reimbursement. Codes include 24640 (subluxation of the radial head), 25600 (closed treatment of distal radial fracture), 26750 (closed treatment of distal phalangeal fracture, without manipulation), 26720 (closed treatment of proximal or middle phalangeal shaft structure), 28510 (closed treatment of fractured toe), 28490 (closed treatment of fractured great toe), and 23500 (closed treatment of clavicular fracture, without manipulation).

5. Neonatal intensive care codes. Many pediatricians dont realize that they can use the neonatal intensive care codes for infants admitted to the hospital after discharge from the newborn nursery, if they are 30 days of age or less at the time of admission. These infants usually are admitted to a pediatric intensive care unit (ICU), not a neonatal intensive care unit (NICU). But you still can use the neonatal intensive care codes. For the admission, you can use 99295 (initial neonatal intensive care), which has a total relative value unit (RVU) of 22.77. Compare this to the critical care services (99291) where the total RVU is 5.60.

6. Urine catheterization. Many pediatricians dont realize that they can code for catheterization using 53670* (catheterization, urethra; simple), and an E/M services code as well.

7. Same-day multiple services. Sometimes a child will be seen two or three times in one day, and then require admission to the hospital. But you can code only one E/M service a day. The way to handle this problem is to use a higher level code for either the office visit or the hospital admission. Make sure you have proper documentation of all the visits in the chart. Another solution is to use prolonged services codes: 99354-99355 for face-to-face outpatient time; 99356-99357 for face-to-face inpatient time, and 99358-99359 for patient care time without patient contact (that is, chart review). Within each pair of codes, the first code signifies an additional 30 to 60 minutes of service. The second signifies an additional 15 to 30 minutes of service.

8. Hospital codes, not normal newborn codes, for ill newborns. For a newborn who is ill meaning more than a minor problem such as toxic erythema (778.8) consider using hospital codes instead of normal newborn codes. Some obvious uses are neonatal fever, tachypnea of the newborn (770.6), and polycythemia of the newborn (776.4).

9. Use RBRVS system. There are many advantages for pediatricians in the resource-based relative value system (RBRVS), especially in the preventative care of children. Compare the total RVUs for preventive-medicine services with those for office visits (see below). Its clear that encouraging your patients to get well-visits is not only a good idea clinically, but it pays as well. Even a fourth-level visit doesnt pay as well as a physical.

99391 (less than one year of age) has a total RVU of 2.12
99392 (1 to 4 years of age) has a total RVU of 2.46
99393 (5 to 11 years of age) has a total RVU of 2.46
99394 (12 to 17 years of age) has a total RVU of 2.80
99212 has a total RVU of 0.66
99213 has a total RVU of 0.94
99214 has a total RVU of 1.48

10. Nebulization, inhalers and spacer training. When the nurse does the training, you should use code 97535, which is self-care training. This code can be billed in conjunction with an office visit. Note that if you use 94664 and 94665 for training and treatment on the small volume nebulizer, you cannot use 97535. For that reason, you should use 94640 for treatment, along with 97535 for teaching.

11. Use HCPCS instead of 99070. Why use 99070 (supplies and materials) when you can use HCPCS for supplies? Insurance companies are more likely to pay for a HCPCS code because 99070 is so general. Common HCPCS codes are a nebulizer administration set (K0168-K0170) and inhalation solution (J7610-J8610).

12. Discharge day service. The discharge day codes are 99238 for 30 minutes or less and 99239 for more than 30 minutes. Because most pediatric and sick neonatal hospitalization discharges require a total of more than 30 minutes, including dictation of discharge summary, remember that they qualify for a 99239 which has an RVU of 2.37, whereas 99238 has an RVU of 1.87.

13. Dont forget seldom-used codes. Many pediatricians simply dont bother to code for some procedures because they do them so rarely. Following are some codes that you should use, regardless of how rarely you use them. Dont give the services away for free.

10060 (incision and drainage of abscess)
11200 (removal of skin tags)
16000 (initial treatment of first degree burns)
20000 (incision of soft tissue abscess superficial)
43760 (change of gastrostomy tube)
94240 (functional residual capacity)
96110 (developmental testing limited)
96111 (developmental testing extended [Bayley
Scales])
99080 (special reports - insurance forms)
99082 (unusual travel - transport patient)
99141 (conscious sedation IV, IM, inhalation)
99142 (conscious sedation, oral, rectal, intranasal)