Pediatric Coding Alert

Question: One of our pediatricians has an established patient whose mother contacted one of our nurses about her daughter having pink eye. The nurse contacted the pediatrician, who was not in the clinic that day, but who told the nurse to have the mother send him a picture of her daughter’s eye by email. After viewing the picture, he prescribed an antibiotic. The pediatrician did not talk to the mother or daughter.

Can I bill a 99421 in this instance?

AAPC Forum Participant

Answer: Yes, you can justify billing 99421 (Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes) in this situation. But you will need to make sure of the following:

1. You will need to exclude the initial contact with the nurse. Per the online digital evaluation and management (E/M) services guidelines, the code requires a physician’s or other qualified healthcare professional’s (QHP) “evaluation, assessment, and management of the patient,” and “clinical staff time is not calculated as part of [the] cumulative time” for the codes.
2. You will need to document that the mother contacted the pediatrician directly with the picture of the patient’s eye, and that the nurse did not receive the mother’s communication and forward it to the pediatrician. This would satisfy the CPT^® requirement that the online digital E/M service was initiated at the patient’s request.
3. You will need to document that the picture was sent to the pediatrician via a secure, HIPAA-compliant platform, such as an electronic health record (EHR) portal, again per the codes’ requirements.
4. You will also need to document that the service did not lead to a related, separately reported E/M service within seven days of the initial online digital service. If this is the case, the work involved in the 99421 would be folded into the bigger, more comprehensive E/M service, and only that E/M service would be billed.