Pediatric Coding Alert

Pediatricians can spend several hours treating a patient for an asthma attack a challenge, both in clinical and coding terms. Document carefully, and code every procedure you perform for maximum ethical reimbursement.

Many pediatricians have faced the following scenario: A panicking mother calls mid-morning to tell you her 8-year-old is having an asthma attack, and she is bringing him in immediately. You mobilize your office to receive the patient. He is rushed into an exam room where he will stay for the next three hours, getting nebulizer treatments, being taught how to use the nebulizer and peak flow meter, and being monitored by the pediatrician and staff. Aside from the fact that the patient will throw your schedule into disarray, you know that if possible, you want to keep the child out of the hospital. But when the patient goes home with clear lungs in the afternoon, you have to figure out how to bill for the asthma crisis. We have a lot of children with bad asthma, says Scott Cuming, MD, FAAP, a solo pediatrician in San Antonio. We have to code everything that we do, or we will lose money.

The documentation and coding of an asthma crisis can be broken into six components: evaluation and management (E/M) level, time, nebulizer treatment, emergency codes, prolonged services codes and pulse oximetry.

1. Choose CPT 99214 or 99215. Asthma cases usually justify a level-four (99214) or level-five (99215) E/M service code. I was coding all of these as 99214s, says Cuming. Then I looked at coding compliance for the 1995 E/M guidelines and realized that I was really doing 99215s much of the time.

A.D. Jacobson, MD, FAAP, former member of the American Academy of Pediatrics (AAP) coding and reimbursement committee and a pediatrician at Pediatric Associates, a four-pediatrician, one-nurse practitioner practice in Phoenix, agrees that treating asthma attacks involves high medical decision-making and therefore calls for higher E/M services codes. But Jacobson warns against using too many 99215s. I rarely use a level five with these patients, and the reason is that I may not meet all the documentation requirements, he says. Theres a lot that you have to do for a level five. A level five, like a level one, is on the far side of the bell-shaped curve for E/Ms. The pediatrician with too many outside codes (99211 and 99215) is damaging the bell-shaped curve, in which the majority of visits should be 99213, and risking potential audits, says Jacobson.

Note: The bell-shaped curve means that the majority of your codes are third level, the fewest are first and fifth level, and second- and fourth-level codes are in the middle but equal. If you [...]