Pediatric Coding Alert

When a pediatrician admits a patient to observation status, keeping the numerous E/M codes straight requires more than a watchful eye. Consider the following scenarios to avoid incorrectly reporting the physician's services, which could result in undercharging or even double-dipping.

1. Same-Day Admission and Discharge

Before CPT created same-day admission and discharge observation care service codes (99234-99236) in 1998, physicians had no way of charging for such services. "Carriers will pay for only one E/M service per day," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. In fact, CPT Codes does not actually state that you can report only one E/M per day. Conventional wisdom and reimbursement experience, however, dictate that insurers will not pay for more than one encounter on the same day. So, carriers would pay for the admission service only and not the discharge service.

Now, instead of using the initial observation care codes (99218-99220) in conjunction with a separate discharge code (99217), physicians have the same-day admission and discharge codes (99234-99236) as an option. These codes have more relative value units (RVUs) than the initial observation care codes (99218-99220), but fewer RVUs than a two-day observation, consisting of an initial observation care code (99218-99220) and a discharge code (99217). Although CPT does not require a minimum length of stay when reporting 99234-99236, Medicare has a minimum time requirement.

For all non-Medicare payers, when a physician admits a patient to observation care and discharges the same day, you should report same-day admission and discharge codes 99234-99236 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ), says Dee Mandley, RHIT, CCS, CCS-P, director of HIS and education services for CURES, a coding and compliance company in Twinsburg, Ohio. You should report 99234-99236, regardless of the length of stay, as long as documentation reflects that the pediatrician performed both an admission and a discharge.

For instance, an emergency department physician calls a pediatrician at home at 2 a.m. regarding a girl who has croup (464.4). The pediatrician admits the patient to observation over the phone. He visits the patient on rounds at 8 a.m. and discharges her.

You should bill a same-day admission and discharge from observation (99234-99236), Scott says. The pediatrician performed two services. He first admits the patient to observation care and subsequently discharges her. Select the appropriate-level same-day admission and discharge observation code based on the complexity of medical decision-making, examination and history documented. These codes, unlike other E/M codes (outpatient services, hospital care, etc.), are not time-based. Link 9923x to 464.4.

You should not report discharge code 99217 because it is for services provided on a different calendar day than the day the physician initiates observation care, Mandley says.

Note: When the pediatrician assesses and discharges a normal newborn from the hospital or birthing room on the same date, use 99435 (History and examination of the normal newborn infant, including the preparation of medical records [this code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date]).

Medicare, unlike other payers, requires an eight-hour stay to report same-day admission and discharge codes. "Time only matters with Medicare," says Kathy Pride, CPC, CCS-P, coding supervisor for the Martin Memorial Medical Group, a 57-physician group practice in Stuart, Fla. Otherwise, the key is that the services occurred on the same calendar day. When charging Medicare for admission and discharge on the same calendar day and less than eight hours, report initial observation care codes 99218-99220 (Initial observation care, per day, for the evaluation and management of a patient ) only, she explains. For stays greater than eight hours, assign same-day admission and discharge codes 99234-99236.

2. Admission From Observation to Inpatient Status

When the same pediatrician admits a patient to inpatient status from observation status on the same day, report only the inpatient admission. You should combine the work performed in both E/Ms to report a higher-level code, Scott says. Do not report the services individually.

For instance, a mother calls her pediatrician for advice regarding her son who has broken out in hives following a bee sting. The pediatrician meets the family at the emergency department and admits the child to observation status. While the patient is in observation care, his symptoms worsen. He develops wheezing (786.07) and requires oxygen. The pediatrician admits the patient to the hospital.

You should report the initial hospital visit (99221-99223) only, says Richard Tuck, MD, FAAP, medical director of quality care partners, PrimeCare of Southeastern Ohio in Zanesville. Do not bill for the admission to observation. "You should not separately report same-day E/M services provided in sites that are related to the admission, such as observation," Mandley says. Instead, include the work involved in the observation services in the admission code. Code to a higher admission level based on the increased time and complexity of medical decision-making involved.

3. Admission to Observation Status From Outpatient

The same rules apply to services provided in the doctor's office that require further E/M outpatient or inpatient observation services.

For instance, a mother visits a pediatrician claiming that her infant vomits after every feeding (783.3, Feeding difficulties and mismanagement). Because the infant is not emaciated, the pediatrician admits the baby to observation status to observe his feeding patterns.

Report 99218-99220 or 99234-99236 for the E/M services provided and documented that day. The doctor should roll the work performed in the office into the observation code, Pride says. "He doesn't need to repeat the elements."

In situations like this that may require more extended observation, consider admitting the patient to the hospital and billing initial hospital care (99221-99223). "Observation codes are useful for an extended emergency room visit in which the doctor can treat and release the patient in a single day," Scott notes. Single-day observation care is appropriate for rehydrating a child or for a chemotherapy patient who requires close nurse observation. For situations when complications may develop, "regular hospital admit codes reimburse better, and whenever you have the option on overlapping possibilities, use the higher-paying code," he recommends. Although initial hospital care codes (99221-99223) contain only slightly higher RVUs than initial observation care codes (99218-99220) 99221 has 1.8 RVUs, compared to 99218, which contains 1.78 RVUs some payers may reimburse admission codes more than observation codes.

Some pediatricians may send patients to children's hospitals in which a pediatrician internist assesses and admits the patient, rather than the pediatrician. In these cases, the pediatrician bills for the office work, and the internist reports the admission.

4. Inpatient Admission Following Initial Observation

When the physician admits a patient to inpatient hospital care on a different calendar day than the initial observation date, the doctor may report the initial hospital care 99221-99223 but not the discharge from observation status.

For example, a pediatrician admits an infant who has a fever (780.6) and wheezing to observation at 6 p.m. on Tuesday. Overnight, the patient's fever rises, and he requires oxygen. The pediatrician admits the patient to the hospital on Wednesday.

For the admission to observation care on Tuesday, assign 99218-99220. For the physician's services on Wednesday, report initial hospital care 99221-99223. Do not report the discharge from observation (99217) because coding rules stipulate one E/M inpatient code per day. Include any work performed during the observation on Tuesday in the initial hospital care code.

If the pediatrician examines the patient on Tuesday in the office before admitting the patient to observation, he combines the office work in the observation care code (99218-99220). If he admits the child over the telephone and does not have a face-to-face encounter with the patient on Tuesday, however, he should bill the hospital admission on Wednesday. "Even though you were technically responsible and liable for the care on Tuesday, you cannot start billing until the patient is first seen," Scott explains. A face-to-face encounter is mandatory, Tuck says.

5. Observation Admission, Different-Day Discharge

When a pediatrician admits a patient to observation status and discharges on a different calendar day, report each service separately.

For instance, the infant who has a fever and wheezing spends an uneventful Tuesday night in the observation unit. When the pediatrician examines the child on Wednesday morning, the child's fever has abated, and the wheezing has subsided. The pediatrician discharges the patient.

For the initial admission to observation status, you should assign 99218-99220. For the discharge on Wednesday, report 99217.

6. Patient Remains in Observation for Two Days

When a patient remains in observation status for two calendar days, the pediatrician should use outpatient office visit codes (99211-99215) for services between the initial admission and discharge.

For example, a girl has a severe anaphylactic reaction to an allergy injection in a pediatrician's office on Thursday at 5:30 p.m. The pediatrician is concerned about delayed reactions and admits the patient to the hospital observation unit. The child has continued but subsiding signs of irritation on Friday, so the pediatrician keeps her in observation status on Friday. On Saturday morning, she has improved, and the physician discharges her.

For the initial observation admission, report 99218-99220. Remember to add the work performed in the office to the admission code. For the pediatrician's services on Friday, report an outpatient office visit (99211-99215). Observation services are considered outpatient services regardless of the place of service, including a pediatric floor, an emergency room or an observation unit. For the discharge on Saturday, assign 99217.

Arguably, most patients requiring two days of observation could justify an inpatient admission with the appropriate inpatient coding. Payers more readily accept inpatient coding than extended observation coding.

7. Consult to Patient in Observation

When another doctor requests a pediatrician's opinion for a patient who is in observation care, the pediatrician reports the consultation, and the other physician bills for the observation services.

For example, a family physician (FP) requests a consultation for an infant who is failing to thrive (783.41). The pediatrician evaluates the infant in the observation unit. "He should use the consultation codes for his work," Scott says. Because the patient is in observation status and therefore considered an outpatient, assign an office consultation code (99241-99245, Office consultation). The FP charges for all observation services.

Suppose the FP admits the child to the hospital, and the pediatrician continues to evaluate the patient. The pediatrician reports subsequent hospital care codes (99231-99233) for following the same problem, Scott says. If the FP requests a second consultation for a new problem or requests a new consultation a few days later for the same problem that reoccurred, the pediatric consultant should report the follow-up consultation codes (99261-99263).