Pediatric Coding Alert

Question: A hospitalist physician asked my pediatrician to see a premature newborn who failed a hospital hearing screening. The pediatrician saw the infant a week later in the office for an initial visit. The pediatrician documented a detailed history, a detailed examination, and low-complexity medical decision-making at the hospital encounter and the office visit. Should I code the E/M services with 99253 and 99203?

Wyoming Subscriber

Answer: No, once your physician has provided a face to face service for the patient, the child is considered an established patient. You should instead submit the hospital encounter as 99253 (Inpatient consultation for a new or established patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity…) and the office visit with 99214 (Office or other outpatient visit for the E/M of an established patient ...), assuming that the nature of the presenting problem supports a level 4 established patient. If not, even though a level 4 has been supported by the volume of the documentation, the encounter may perhaps be downcoded to 99213 to meet the medical necessity.

Even though the infant is new to the office, you should report an established patient office visit (99211-99215), not a new patient E/M service (99201-99205, Office or other outpatient visit for the E/M of a new patient ...). CPT^® defines a new patient as one who hasn’t received any professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Because the pediatrician had a face-to-face visit with the infant at the hospital, the patient became an established patient for subsequent E/M encounters.

And the office visit’s documentation qualifies as a level-four established patient office visit (99214) instead of a level-three new patient E/M (99203). Unlike a new patient office visit, which requires all three key components, an established patient office visit only requires two. Therefore, you may report the E/M service with 99214 assuming the medical necessity and documentation of the problem supports the level 4 visit.