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 have too many second-level codes and not enough fourth-level codes, the curve will be skewed to the left, and you will not be getting reimbursed properly. Practices can be punished for using too many low-level codes as much as they are for too many high-level codes. (For more on the bell-shaped curve see Improve Reimbursement for Office Visits with Bell Curve on page 11 of the February 2000 Pediatric Coding Alert.)

Many pediatricians reason that the insurance company would have to pay more than a 99215 if the child were admitted to the hospital and therefore will not deny 99215. But Jacobson warns against this rationale. It sounds good, but it doesnt sound good when the auditor comes in, he says.

The bottom line is: Coding for patients with an asthma crisis calls for a 99214 or 99215, providing that your documentation properly supports these high-level E/M services codes.

2. Document time. Pediatricians cannot use time as a factor when coding for an asthma crisis (unless 50 percent or more of the visit is spent on counseling). Documenting the time you spend with these cases, however, is helpful if an insurance company representative ever looks at your charts. I document all my time, and I document what I do during that time, says Cuming.

In the case of an asthma attack, insurance companies usually understand that more than one procedure and service are rendered, says Cuming. If the patient is in status, you have a good argument with the insurance company, he says. You let them stay in the office for a couple of hours, you educate the child and the parent on peak flows and the nebulizer, you get the peak flows out of the red zone into the yellow zone you do all that work, and you should write down how much time you spend doing it.

3. Correctly code nebulizer treatments. The code for providing nebulizer treatments is 94640 (nonpressurized inhalation treatment for acute airway obstruction). Use 94640 for each treatment. The first treatment should be coded without a modifier, and modifier -76 (repeat procedure by same physician) should be appended to subsequent treatments.

Note: Modifier -76 on repeat nebulizer treatments is technically accurate, says Richard Tuck, MD, FAAP, a member of the AAPs coding and reimbursement committee. But you dont necessarily have to use it we dont, and we have no problems getting paid for multiple nebulizer treatments with 94640.

Cuming and Jacobson also recommend billing 97535 (self care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of adaptive equipment] direct one-on-one contact by provider, each 15 minutes) for training patients and parents in the use of the nebulizer and peak flow meter. I always end up teaching, so I code 97535, says Cuming. (For more on coding nebulizer treatments see Get Proper Reimbursement for Multiple Nebulizer Treatments on page 65 of the September 2000 Pediatric Coding Alert.)

4. Use emergency care codes. For an asthma crisis you should also code 99058 (office services provided on an emergency basis) because the patient is coming to you on an emergency basis. An asthma patient in status is an emergency by definition, says Cuming.

Jacobson agrees, noting that the new asthma diagnosis codes (493.02-493.22) citing acute exacerbation also warrant an emergency service. Acute exacerbation of asthma is enough for an emergency office visit and enough to justify a fourth- or fifth-level code, he says.

The new asthma diagnosis codes are 493.02 (extrinsic asthma, with acute exacerbation), 493.12 (intrinsic asthma, with acute exacerbation), 493.22 (chronic obstructive asthma, with acute exacerbation), and 493.92 (unspecified asthma, with acute exacerbation).

Jacobson notes that the acute nature of the condition usually warrants the emergency code, but that any asthma management case is usually a level-four or level-five visit. The medical decision-making justifies it, he explains. (Note that in addition to meeting the criteria for medical decision-making, you must also meet the criteria for a level-four or level-five exam or history to bill those E/M levels.)

5. Consider prolonged services codes. Pediatricians may also be able to get reimbursed for prolonged services codes in this scenario. They are justified by the intensity as well as the time spent, says Jacobson. These codes are 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]) and 99355 (each additional 30 minutes [list separately in addition to code for prolonged physician service]). Codes 99356 and 99357 are for inpatient use.

Cuming sometimes uses prolonged services codes and gets paid for them, but not without a battle. If the patient is here long enough, I will bite the bullet and bill the prolonged services codes, he says. Because I document everything I do, and how long it takes me, I feel I have a good case.

6. Dont forget pulse oximetry. Pediatricians often wonder if they can bill for pulse oximetry and peak flow readings taken during the asthma crisis encounters. Now, you can bill 94760 (noninvasive ear or pulse oximetry for oxygen saturation; single determination) for pulse oximetry. But Medicare bundles this code into the office visit codes, so if your managed-care company follows Medicares Correct Coding Initiative (CCI), you will not be paid separately for 94760. Jacobson recommends trying to bill for it anyway. Pediatricians, however, cannot bill for peak flow readings done on the hand-held meter.

Preparing the Claim

Here is an example of a claim for a patient having an asthma attack:

99215
94640
94640-76
97535
99058
99354

Bonnie Kanatzar, Cumings office manager, is opposed to filing the claim electronically for asthma crisis. Its easier to just send the documentation along with the claim, she says. If you know its going to be complicated, or that youre going to have a problem, why deal with the denial at all? You could file electronically and go through the long process of appealing, or you could just send the documentation with the claim in the first place.

Coding a Subsequent Hospital Admission What happens if a child having an asthma attack is admitted to the hospital despite all the pediatrician has done? That changes the entire coding picture because its very difficult to bill 99215 plus the hospital admission codes. I would recommend billing 99215 and the hospital admission, with a modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit, says Scott Cuming, MD, FAAP, a solo pediatrician in San Antonio. And I would be prepared to explain to the insurance company that I saw the child at 8 in the morning, and the patient left my office in stable condition, but relapsed later that night, and I had to admit the child. But Cuming admits that getting paid for two evaluation and management (E/M) visits on the same day is difficult. Youre in trouble if theyre the same or a related diagnosis, he says. Technically, following CPT methods, you should bill based on where the patient ended up for the day, says Thomas Kent, CPC, CMM, principal of Kent Medical Management, a coding and practice management consulting firm based in Dunkirk, Md. If the patient is admitted, even for a different problem, drop the office visit, says Kent. The work done in the office is included in choosing the admission code so nothing is lost. But Kent does not disagree with the option of billing for both the hospital visit and the office visit using modifier -25. It is possible to be paid for two E/M services codes in the same day for different reasons but its difficult.