Pediatric Coding Alert

Question: Do we need to use a modifier when coding prolonged services or special services?

Illinois Subscriber

Answer: No. These codes are add-on codes that you report in addition to the E/M code without a modifier.

Example: At an ob-gyn's request, a pediatrician attends an emergency cesarean delivery that occurs at midnight. The pediatrician examines the newborn and admits her to the hospital. You can code on the claim:

• the attendance at delivery with 99436 (Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn)

• the after-hours hospital services as 99053 (Service[s] provided 10 pm to 8 am at 24-hour facility)

• initial hospital care with 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...).

Note: CPT does not require modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on 9922x with 99436. But when you report this code combination, payers may require modifier 25 on 9922x to indicate the hospital care (9922x-25) is a significant, separate service from the attendance at delivery (99436).

Similarly, you would not need a modifier to report a prolonged service. For instance, if a pediatrician spends 70 minutes face-to-face with a patient on a 99215 encounter, you would report 99215 (Office or other outpatient visit for the E/M of an established patient ... Physicians typically spend 40 minutes with the patient) and +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]).

The first prolonged service code requires a minimum of 30 minutes beyond the time CPT indicates that physicians typically spend on the coded service -- 40 minutes for 99215.