Pediatric Coding Alert
Re-Examine Critical Care-Test Denial Claims
Question: When we report CPT 99291 for in-office critical care in addition to influenza and RSV test, the insurance carrier bundles the labs into the critical care. Does the E/M include the labs? Answer: The critical care codes do include many CPT codes, but not an influenza or respiratory syncytial virus (RSV) test. You could send the insurer a copy of CPT's critical care services notes that state 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) includes the following codes: Point out that CPT does not include the tests you performed to determine the child's illness. - Answers to You Be the Coder and Reader Questions provided by Debbie Abel, AuD, audiologist at Northern Arizona Speech and Hearing Center in Sedona, Ariz., and owner of Alliance Audiology in Alliance, Ohio; Richard A. Molteni, MD, FAAP, a neonatologist and medical director at Children's Hospital and Regional Medical Center in Seattle; Pat Wildman, RHIA, CCS-P, clinical reimbursement auditor at Children's Hospital Boston Compliance Department; and Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo.
Oklahoma Subscriber
Tip: Double-check that you're using the right RSV code. You should use 87807 (Infectious agent antigen detection by immunoassay with direct optical observation; respiratory syncytial virus) for RSV Binex NOW, as well as Integrated Biotechnology's RSV test called Integrated Biotechnology Quick Lab.
You should no longer report the test with unlisted-procedure code 87899 (Infectious agent detection by immunoassay with direct optical observation; not otherwise specified). CPT 2005 introduced a specific code for the in-office RSV test.
You may also want to look at the ICD-9 codes you report. If you do not make a definitive diagnosis of influenza (487.x) or RSV (079.6) in the chart, use the patient's signs and symptoms for the test codes. For instance, link the flu test (87804, Infectious agent antigen detection by immunoassay with direct optical observation; influenza) to the patient's chief complaint(s), such as nausea with vomiting (787.01) and/or chills with fever (780.6).
Pediatric Coding Alert
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Re-Examine Critical Care-Test Denial Claims
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Go to AAP Web Site for Menactra Letter
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