Pediatric Coding Alert

Failing to report CPT 99058 when your pediatrician interrupts her schedule to provide emergency care to a child is not only incorrect coding, it may also cost your practice more than $10 per episode.
 
But if youre like most pediatric coders, you rarely use 99058 (Office services provided on an emergency basis) a fact that led the American Academy of Pediatrics (AAP) to rank 99058 as one of the top 10 underused pediatric codes.

Many pediatric coders never use this code, for a variety of reasons, says Curtis C. Cherry, CPC, pediatrics coding supervisor for the Department of Defense at Fox Army Health Center. Perhaps because the Blue Cross Blue Shield fee schedule does not contain the emergency office code, they assume no insurers cover the service. Other coders may have stopped using 99058 after receiving denials, he speculates. And some, unfortunately, do not know the code exists.

Whatever your excuse is, when your pediatrician provides unscheduled in-office emergency care, you should report 99058 in addition to an office visit (99201-99215), according to CPT. Regardless of whether insurers cover 99058, coding convention requires you to code to the highest specificity possible. Omitting 99058 for a patient who requires office services on an emergency basis is not accurately reporting the visit.

Further, if you dont bill the service, youll never get it paid. Medicaid and some other payers reimburse for the underutilized code, Curtis says. For instance, South Carolina Medicaid pays $10 for 99058. So, stop missing opportunities for reporting this code with some expert suggestions on when to use the emergency-basis office service code and how to get insurers to cover it.

 
To optimize the emergency service code, you should know which same-day sick patients qualify for 99058. Although pediatric offices may have walk-in patients who require same-day care, not all of these visits warrant the special service code. You should use the code when the childs clinical condition demands immediate physician care and the pediatrician must interrupt her or his regularly scheduled appointments to see the patient, says Cherry, who is also a coding and reimbursement teacher at the University of Northern Alabama.

Therefore, when dealing with triage scenarios, use 99058 if your pediatrician believes that the situation is indeed an emergency. Suppose after a nurse triages a walk-in patient, she gradually works the child into the schedule. In this case, you should not bill 99058, says Kim Kieke, CPC, of Austin, Texas. If, however, the nurse triages the patient and the childs condition warrants immediately interrupting the pediatricians scheduled appointments to attend to the patient next, you are justified in billing 99058.

Due to the nature of pediatrics, 99058 may also apply in some parent-deemed emergency walk-in instances. For example, after picking up her child who has a cold (460, Acute nasopharyngitis [common cold]) and fever (780.6) from day care, a mother presents to the pediatricians office and demands immediate attention. Some reassurance from the triage staff that they will work the child in to see the pediatrician as soon as possible can usually appease most demanding parents, Kieke says. If that doesnt work, and they continue to demand that the physician interrupt scheduled appointments to see what they perceive as their seriously ill child, bill 99058.

Because 99058 requires interrupting the physicians scheduled appointments, 24-hour clinics do not usually qualify for the code. When the doctors practice has urgent-care slots available in the schedule and patients are fit into the schedule, do not report 99058, states CPT Assistant Winter 1994. If the clinic operates on a walk-in and triage basis, the patient with the emergency is automatically triaged to the front of the line. Because the process does not interrupt the physicians schedule, in this case 99058 is inappropriate, Kieke says.

On the other hand, if a pediatrician has to leave one patient to attend to an urgent-care patient next, a clinic may justify using 99058. Discuss this possibility with your carriers to see if they will pay for 99058 separately in those instances, Kieke says. If they agree, you have it in the contract that they will pay. If they dont agree, add 99058 to your contract as a noncovered service. That way, if the situation arises, you can collect the charge from the patient.

 
To improve coverage for 99058, encourage your pediatricians to note the specifics of the patient-care interruption. If the pediatrician states that rather than attending to the next scheduled patient, she has to treat an emergency child, she has a strong argument to show the insurer why the situation justifies the emergency-basis office service code. Most physicians, however, do not supply the documentation to support 99058, Curtis says.
 
The documentation does not need to be extensive. For a child who requires the pediatrician to see him before scheduled patients, a quick note could read, Had to treat emergency child out-of-turn.