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.
1. Bill 99058 for Interrupted Schedules  
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. [...]