Pediatric Coding Alert

Question: Does a therapist qualify as a physician extender? A respiratory therapist (RT) who runs our asthma clinic spends an hour with a new patient and 30 minutes on a recheck. The pediatrician then discusses the plan with the family and writes prescriptions. May we charge 99215 and 99214 for the hour and half-hour visits?

Ohio Subscriber

Answer: An RT doesn't count as a physician extender. So, you may not report higher-level E/M services under her personal identification number or incident-to the pediatrician as you may for nonphysician practitioners, such as nurse practitioners and physician assistants. You will instead have to split the visit's billing.

Suppose at a new patient visit, the RT spends 60 minutes taking a history, performing an assessment and providing asthma teaching and medication information. The pediatrician then reviews the RT's findings and spends 15 minutes discussing the plan with the family.

In this case, you may report either the RT's health and behavior assessment or the pediatrician's E/M service. The National Correct Coding Initiative doesn't permit you to bill health and behavior assessment/intervention (96150-96155) on the same day as an office visit (99201-99215).

You could assign 96150 (Health and behavior assessment [e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires], each 15 minutes face-to-face with the patient; initial assessment) x 4 units for the RT's initial 60-minute health and behavior assessment. Or you could report 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) based on time for the pediatrician's 15-minute counseling-dominated service.

You'd be better off reporting 96150, if the patient's insurer reimburses the service. You'd receive over $106 for 4 units of 96150 ($26.51 based on the 2004 National Physician Fee Schedule Relative Value File that private payers often follow). Code 99213 pays $51.87.

For rechecks in which the RT spends 30 minutes and the pediatrician spends 10 minutes, you'd also receive more money billing 96151 (... re-assessment) x 2 units instead of 99212 (... 10 minutes face-to-face ...). Code 96151 x 2 pays $50.78 compared to $37.15 for 99212. To avoid losing the pediatrician's service, you could have the child return for a different-day E/M.