Pediatric Coding Alert

Question: A pediatrician saw a child in the hospital under observation and spent three hours of total direct contact and an additional two hours of indirect contact. The case was then turned over to Child Protective Services.

The insurer paid the direct prolonged services codes but not the indirect. Should I appeal with notes, or should I have not billed both direct and indirect?

Nebraska Subscriber

Answer: You should have billed only the indirect prolonged services (+99358, Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests, communication with other professionals and/or the patient/family]; first hour [list separately in addition to code[s] for other physician service[s] and/or inpatient or outpatient evaluation and management service] and possibly +99359, ... each additional 30 minutes [list separately in addition to code for prolonged physician service]). Observation codes (99218-99220, Initial observation care; and 99234-99236, Observation or inpatient care services [including admission and discharge services]) represent face-to-face time. So you may bill non-face-to-face time that the pediatrician spends on patient care before or after the direct observation service with 99358 and possibly 99359.

Problem: Because observation codes are not time- based, you cannot bill direct prolonged services (+99354, Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service] and +99355, ... each additional 30 minutes [list separately in addition to code for prolonged physician service]).

The prolonged service codes are for prolonged physician service "beyond the usual service." Since CPT does not assign a typical time to each observation code, there is no way to calculate how many direct minutes the pediatrician spent beyond the chosen code's usual service. In fact, CPT does not list the observation codes as base codes for 99354-99355 in the parenthetical instruction following 99354.

Best bet: In time-consuming situations such as these, admit the patient to the hospital. Admission codes (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) allow you to use time as the controlling factor in the E/M code selection if  counseling and/or coordination of care comprise the majority of the visit and to report direct prolonged service codes. For instance, if the pediatrician had admitted the patient to the hospital and discharged him the next day, you could have reported the appropriate-level hospital care code, such as 99223, and then calculated how much time beyond that code's typical time, 70 minutes for 99223, the physician spent on face-to-face inpatient prolonged services.

You could then assign +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour [list separately in addition to code for inpatient evaluation and management service]) and possibly +99357 (... each additional 30 minutes [list separately in addition to code for prolonged physician service).

Do this: Because you can not retroactively change the patient's hospital order, choose the appropriate-level same-day observation admission and discharge code based on the components the pediatrician performed and documented, such as 99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ...), which requires a comprehensive history, comprehensive examination and high-complexity medical decision-making.

If you use the highest-level observation code in this category (99236), consider appending modifier 21 (Prolonged evaluation and management services) to the code. The modifier requires no specific prolonged service time (or reimbursement). Then you can also appropriately report the non-face-to-face prolonged service with 99358 and possibly 99359.

Answers to You Be the Coder and Reader Questions answered/reviewed by Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn.; Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG in Egleston, Ga.; and Richard H. Tuck, MD, FAAP, a national pediatric coding speaker and educator.