Pediatric Coding Alert

Question: Our office is open on Saturdays. What ICD-9 codes would the claim require to use 99051?

Ohio subscriber

Answer: Code 99051 (Service[s] provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) is not diagnosis related. The code simply requires that your office have posted evening, weekend and holiday hours and the physician provide the basic service (such as 99201-99215, Office or other outpatient visit) during those times.

For instance, you have posted hours of 9 a.m. to 12 p.m. on Saturday. On Sat., April 6, the pediatrician provides a level-four new patient office visit for an infant with otitis media (382.9, Unspecified otitis media) and high fever (780.6), a level-three established patient office visit for a teenager with acute upper respiratory infection (465.9), a level-three established patient office visit for a toddler with a swollen foot from an insect bite (916.4, Insect bite nonvenomous of hip thigh leg and ankle without infection) (E906.4, Bite of nonvenomous arthropod), as well as two 99212s, one 99203, five additional 99213s and two 99204s. You could code 99051 as a separate line item in addition to the E/M service on all these claims.

Catch this: If a child’s condition requires the physician interrupt his schedule to provide emergent care to the patient, you could also report 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) in addition to the office visit code. Possible diagnoses that could require emergency care include open wound (870-879), asthma attack (493.12, Intrinsic asthma; with [acute] exacerbation), anaphylactic shock (995.0, Other anaphylactic reaction) due to bee sting (989.5, Toxic effect of venom; E905.3, Sting of hornets wasps and bees causing poisoning and toxic reactions) or peanut ingestion in an allergic patient (999.4, Anaphylactic reaction due to serum), head injury (959.01, Other and unspecified injury to head).

You could report two special services codes on the same claim. For instance, for a child who fell from his bike, a pediatrician assesses a head injury and repairs a 2.3 cm leg laceration that requires the physician to interrupt his schedule to treat. You could report these codes:

·         99213-25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) with 959.01 for the head injury evaluation and E826 (Pedal cycle accident).

·         12031 (Repair, intermediate, wounds of scalp, axillae, trunk and/or extremities [excluding hands and feet]; 2.5 cm or less) linked to 891.0 (Open wound of knee, leg [except thigh], and ankle; without mention of complication) and E826

·         99051 with 959.01, 891.0, E826 for the Saturday treatment

·         99058 linked to 891.0 and E826 for the emergency-based service.

Beware: Not all insurers, however, will pay for multiple special service codes reported on the same claim. You should also note that most payers will not pay for the after-hours code 99051 when associated with preventive medicine services (99381-99385 and 99391-99395), which they consider elective.