Pediatric Coding Alert

Question: Please advise on the correct use of 99354-99355 in conjunction with 90780-90781 to get reimbursed for the extra time spent monitoring the patient.

Anonymous VA Subscriber

Answer: Some pediatric practices do intravenous therapy in the office. The codes for intravenous infusion (90780 for up to one hour, 90781 for each additional hour, up to eight hours) are time-based and cannot be used in addition to the prolonged services codes (99354 for the first hour, 99355 for each additional half hour). There is no way to use them both together. The first step is to select the level of office visit you want to uselikely a 99214 or 99215. Then, you have a choice between using the intravenous infusion codes or the prolonged services codes. But bear in mind that the verbiage describing these codes indicates that a certain level of participation is required by the pediatrician. For example, the intravenous infusion codes require the presence of the physician during the infusion. However, the pediatrician need not be present face-to-face while the drug is being administered via IV, only to start the IV. The physician can see other patients as long as he or she is always in the office (or hospital floor) to monitor the IV.

Specifically, the descriptor says the infusion must be administered by physician or under direct supervision of physician. Likewise, the prolonged services codes require direct (face-to-face) patient contact that is beyond the usual service.

Note: Although you cannot use prolonged services and IV infusion codes together, they can both be used on the same day. They simply cant both refer to the same block of time. However, it may be difficult to convince the insurance plan to pay this combination.

Finally, you need to compare the fees your health plan pays for the intravenous infusion codes to the prolonged services codes. According to HealthCare Consultants 1999 Physicians Fee and Coding Guide, 90780 pays from $95 to $116, and 90781 pays from $47 to $56. In comparison, fees range from $135 to $165 for 99354 and from $65 to $80 for 99355. As you can see, the prolonged services codes do tend to pay better; however, remember that rates vary widely for prolonged services codes, and some insurance companies dont even recognize them. In this case, it is recommended that you file a paper claim and send a letter with it.