Pediatric Coding Alert

Question: Our pediatrician saw two patients who left the office by ambulance. One was in respiratory distress and had to have oxygen administered until the ambulance arrived, and the other had a grand mal seizure. Our office manager wants to know how to bill for these visits. I feel they should bill a 99215 for both. Is that accurate?

Answer: It’s difficult to say which code the documentation supports, but in general, the majority of patients who leave the office in an ambulance are facing a life-threatening illness. Therefore, many practices can justify using a critical care code (such as 99291 or +99292), based on the amount of time that the physician spent with the patient.

Although many practices believe that they can only report critical care codes in the hospital, this is inaccurate. Patients need not be in a "critical care" unit to report these codes. Instead, CPT^® instructs that the codes apply to "critically ill or critically injured patients."

This is considered to be patients with organ system failure or to prevent progression of organ system failure. It is also appropriate to bill an E/M code for the associated evaluation of the patient, but the time cannot be double-counted. You must separate E/M and critical care time.