Pediatric Coding Alert

Question: I was told to bill only one E/M service per calendar day. Does this apply to all codes in the CPT E/M section?


Illinois Subscriber


Answer: Billing one E/M service per calendar day is an important E/M concept that you should follow unless an exception applies.

Report one E/M service when two encounters involve the same diagnosis. For instance, you should not bill for an office and inpatient visit on the same day. If a pediatrician admits a child from the office to the hospital for dehydration and performs the first face-to-face hospital encounter the same day, you should report only the initial hospital care code (99221-99223).

But if the pediatrician treats the patient for two distinct illnesses, you should code each encounter. For instance, a physician sees a patient in the morning for pharyngitis. Later that day, the patient falls down the stairs and the pediatrician sees the child for multiple contusions.

You should code the first visit with 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) and the second with 99213-25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). Link each visit to the separate diagnosis--99213 to 462 (Acute pharyngitis), and 99213-25 to 920-924 (Contusion with intact skin surface) and E880.9 (Fall on or from stairs or steps; other stairs or steps).

Separate diagnoses may also support reporting both a preventive medicine service and a problem-related visit. If a pediatrician finds a significant, separate problem at the time of a preventive medicine service (99381-99384, New patient; 99391-99394, Established patient), you can bill both E/M services using modifier 25 on the problem-oriented visit code (99201-99215, Office or other outpatient visit).

Other codes in CPT's E/M section that are exempt from the one-E/M-per-day rule are hourly critical care codes (99291-99292, Critical care, evaluation and management of the critically ill or critically injured patient ...) and newborn resuscitation (99440, Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output).

Add-on codes, such as prolonged services (99354-99359), can also be reported--in fact must be reported--in addition to another E/M service.