Pediatric Coding Alert

Question: Our pediatrician wants to start billing 99058 when an emergency interrupts other scheduled services. Can you offer guidance for reporting 99058 with an E/M code or modifiers?

Maryland Subscriber

Answer: Many insurers reimburse for 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service), but keep a few things in mind before reporting the code.

The patient must present and disrupt normal scheduling. For example, a mother brings in her son because of an acute asthma attack. If your schedule is full but you promptly take him to an exam room, this service qualifies for 99058. If you saw him right away but had an opening in the schedule, you wouldn't report 99058. Needing to see the child right away can also apply when the phone staff tells parents who call your office to bring the child in as soon as possible. Both situations disrupt the pediatrician's schedule, so they qualify for 99058. Include the appropriate E/M code for services, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...), and codes for any other services performed such as nebulizer treatment for the asthma patient with 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing {IPPB} device]).

Ask yourself a simple question: If the provider couldn't see the child right then, would you send the parent to the ER? If the answer is yes, and you saw the child despite not having openings in your schedule, the visit probably qualifies for 99058.

Modifier note: Reporting 99058 and the associated E/M code together doesn't require a modifier. Some payers, however, only cover the encounter when you include modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If one of your payers falls in this category, get the policy in writing (by email or other written communication) because it isn't consistent with CPT guidelines.