Pediatric Coding Alert

Often, pediatricians must discuss a patients care via telephone with other healthcare providers. Depending on the situation, this service may be reported using one of three kinds of codes.

Care Plan Oversight Codes

Care plan oversight codes (99374-99375 and 99377-99378) cover many services: development or revision of care plans, review of subsequent reports of patient status, review of related laboratory and other studies, and communication. CPT explicitly allows physicians to claim these codes for telephone calls for assessment or care decision with other healthcare or nonphysician professionals involved in a patients care, integration of new information into the medical treatment plan or adjustments of medical therapy. To bill these services, add the total minutes per month spent discussing a patient and choose the correct code based on time.

If the telephone conversation refers to a patient under the care of a home health agency, 99374 applies for 15-29 minutes per month. Code 99375 should be reported for 30 or more minutes per month. Track every minute spent discussing the childs care, and support the claim with documentation.

As an example, a child might be a high-risk graduate of the neonatal intensive care unit, on home oxygen or a home ventilator. The pediatricians time discussing the case with the home health agency could easily add up to more than 30 minutes in a month (99375).

Another, more common example is the newborn on home phototherapy. This therapy, however, often lasts just a few days, and telephone time can only be billed if it totals 15 or more minutes per month.

For a child in hospice care, report 99377 for 15-29 minutes and CPT 99378 for 30 minutes or more.

Note: Only one physician is allowed to report care plan oversight codes per patient during a given time.

Telephone Call Codes: 99371-99373

Many pediatricians use telephone call codes to bill for conversations with parents or patients, but they dont realize they can also access these codes for time spent talking to other healthcare providers.

Report 99371 (telephone call by a physician to patient or for consultation or medical management or for coordinating medical management with other health care professionals ...) for a simple or brief discussion, 99372 for an intermediate-level discussion and 99373 for a complex or lengthy discussion. According to CPT, these codes apply whether the physician talks to a physician, nurse, pharmacist, nutritionist, physical therapist or any other healthcare provider who is helping to care for the patient.

Code 99371 might be appropriate, for example, for a child with an unusual rash that the pediatrician wants to discuss with the dermatologist. It is also used when briefly discussing lab reports, clarifying pervious instructions or adjusting current therapy.

A 99372 scenario could involve a conversation between the pediatrician and a pediatric pulmonologist concerning a child with allergies or asthma. Also use this code when discussing test results in detail, coordinating management of a new problem in your patient, discussing new information on your patient or initiating a new treatment plan.

For 99373, a pediatrician might discuss the underlying causes of a childs congestive heart failure with a cardiologist. This code also applies when coordinating complex services of several different health professionals caring for your patient.

Insurance companies dont like to pay for telephone call codes, partly because they assume the codes will be used to represent time spent talking to patients (a valid use of the codes according to CPT, but not according to some payers). If the claim is denied, call the provider representative and explain that the calls were spent discussing a case with another physician or healthcare provider, not with the patient.

Prolonged Services +99358 and +99359

If a telephone call lasts more than 30 minutes, and if the pediatrician sees the patient for a procedure or service the same day, you may bill for the call using prolonged services, says Charles J. Schulte III, MD, FAAP, the American Academy of Pediatrics representative to the CPT advisory committee. Use +99358 for the first 30 to 75 minutes and +99359 for each subsequent 30 minutes. These are add-on codes that should be listed only in addition to an E/M service.

Note: Do not list the + on the claim form.

For example, prolonged services could apply if the pediatrician sees a child in the emergency department for an acute behavioral problem the child could not control his temper and attacked his mother and discusses the case with the psychologist and psychiatrist while there.

When treating a patient in the hospital, include all floor time when adding up the minutes to be used for prolonged services, including time spent discussing care with subspecialists on the telephone.

Bill E/M Based on Time

Rather than billing for prolonged services, you may upcode the E/M service based on time spent on the telephone on the hospital floor, explains Richard H. Tuck, MD, FAAP, founding chair of the AAP committee on coding and reimbursement and a practicing pediatrician in Zanesville, Ohio. You might be seeing a child on the unit, and have the nurse call a specialist so you can discuss the case right there, he explains. That would justify a higher-level code, as long as you make the call on the floor. CPT outlines the following time definitions for established patient office visits: 99212 (10 minutes), 99213 (15 minutes), 99214 (25 minutes) and 99215 (40 minutes).

Negotiate for Payment

Ultimately, you must make sure your insurance contracts cover payment for telephone calls. If your practice performs this service often, you should work its payment, code by code, into the contracts with insurance companies when negotiating. Negotiate options to bill for all of the above recommended codes.

Track Prolonged Services Codes, Even if Unpaid Although providers often have difficulty gaining reimbursement for prolonged services, such claims are usually paid on appeal if the time is clearly documented and the services provided support this time. But even when prolonged services are not paid, Thomas Kent, CMM, CPC, president of Kent Medical Management of Dunkirk, Md., recommends that you report the code anyway, for the following reasons: Tracking. Reporting the prolonged services code helps keep track of time and services rendered even if they are not paid. You can use this information in future contract negotiations or to determine which insurance plans you should drop. Communication with patients. Reporting also informs the patient of services rendered that the insurance company will not pay. The patient may be more understanding if you have to drop out of that particular insurance plan. Fees to physicians. Finally, reporting the code keeps your own physicians aware of what is being reimbursed. If one provider in a group attracts many high-need patients, his or her revenue may be low, even though the charges are high. In effect, this pediatrician is giving away his or her services for free, and should know it.