Pediatric Coding Alert

Question: My pediatrician sees a 10-year-old boy for an asthmatic attack. She spends 30 minutes with the child and leaves the room. The nurse nebulizes him (94640). Then the doctor returns for two minutes and listens to his lungs following the nebulizer treatment. Should I bill 99214 and 99354 for the pediatricians time?

Georgia Subscriber

Answer: No, she should report only 99214 (Office or other outpatient visit for the E/M of an established patient physicians typically spend 25 minutes face-to-face with the patient and/or family) for the E/M service. Only face-to-face physician time counts for direct prolonged services. So, in this case, the total direct time that the pediatrician should report is 32 minutes. After billing 99214, which accounts for 25 minutes of her time, she has seven uncoded minutes. You may start reporting +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service ...; first hour ) after the pediatrician spends an additional 30 minutes past the office visit code. Therefore, the visit does not qualify for 99354.

You may not use modifier -21 (Prolonged E/M services) on the office visit code. Modifier -21 applies only to the highest-level E/M service within each category 99215 for established patient office visits, according to CPT Appendix A, Modifiers.

Answers provided by Richard A. Molteni, MD, FAAP, a neonatologist at Childrens Hospital & Regional Medical Center in Seattle; and Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.