Pediatric Coding Alert

When selecting codes for short-stay hospital patients, pediatric coders should consider the site of service as well as the time spent by that patient in that site. These codes include same-day hospital admission and discharge (99234-99236, Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date ), hospital admission (99221-99223, Initial hospital care, per day ), hospital discharge (99238-99239, Hospital discharge day management), initial observation (99218-99220, Initial observation care, per day ), observation discharge (for second day) (CPT 99217 , Observation care discharge day management ), hospital observation status after 24 hours (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient ) and emergency department (99281-99285, Emergency department visit ).

Some service scenarios require same-day observation care codes 99234-99236. The place of service may vary, including the observation unit, emergency department or inpatient unit. The patient need not be in an observation area designated as such by the hospital to report these codes, says Richard H. Tuck, MD, FAAP, founding chair of the American Academy of Pediatrics (AAP) coding and reimbursement committee and a practicing pediatrician with PrimeCare Pediatrics in Zanesville, Ohio.

Hospital unit: For example, a parent brings a child with wheezing to the emergency room at 5:30 a.m. The pediatrician, while doing morning rounds, examines the child and admits him at 7:00 a.m. for bronchiolitis (466.19, Acute bronchiolitis due to other infectious organisms). The patient's oxygen saturations improve and wheezing resolves during the day, and the pediatrician discharges the patient at 6:00 p.m. with a nebulizer. In this case, you should use a same-day observation or inpatient admission and discharge code (99234-99236).

Observation unit: In another example, a pediatrician sees a dehydrated child in the office at 1:30 p.m. The child had presumed infectious gastroenteritis (009.1, Ill-defined intestinal infections; colitis, enteritis, and gastroenteritis of presumed infectious origin), and although vomiting and diarrhea have abated, the child still cannot tolerate oral fluids. The pediatrician sends the child to the observation unit in the hospital for intravenous rehydration. After six hours, the child is stabilized and discharged. You should use a same-day hospital admission/observation and discharge code (99234-99236) for the office visit and the observation admission and discharge combined. The code probably will be a higher-level code at least 99235 because it will incorporate the work of the office visit. Link 99234-99236 to diagnosis codes 276.5 (Disorders of fluid, electrolyte, and acid-base balance; volume depletion) and 009.1.

Note to Medicare coders: Medicare requires observation stays of less than eight hours to be billed with office visit or consultation codes, says Tom Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md. But for private payers, same-day admission and discharge of less than eight hours can be billed with 99234-99236.

Observation in emergency department: Some hospitals no longer have observation units or never had them. Instead, the emergency department may function as an observation unit. For example, the pediatrician directs a mother to take her child to the emergency department following a bee sting. The mother says that the child has broken out in hives (708.9, Urticaria, unspecified). The pediatrician meets the family in the emergency department and notices no further reaction. Nonetheless, the physician directs that the child remain in the emergency department until he or she returns for another examination. Two hours later, the pediatrician returns and, after examining the patient, discharges the patient. For this case, you should report a same-day hospital admission and discharge code 99234-99236.

Consultation in emergency department: If the pediatrician performs a consultation in the emergency department, you should use the office consultation codes. For example, the mother of a child with an earache (382.00, Acute suppurative otitis media without spontaneous rupture of ear drum) goes to the emergency room with the child. The emergency physician calls the pediatrician, requesting a consultation. In this case, the pediatrician would not bill 99234-99236 but instead would bill the appropriate outpatient consultation code (99241-99245). The pediatrician must act as a consultant and not take over primary care of the patient to bill a consultation. Do not bill an emergency department code (99281-99285), says Diane Kirkle, CPC, professional medical coding curriculum instructor at Creighton Medical Associates in Omaha, Neb. "The ED physician will bill those codes," she says. "The pediatrician should bill the consultation."

Multiple visits on same day: If you see the patient on the same day in two sites of service, you should upcode the E/M service accordingly if there is medical necessity. For example, a pediatrician sees a patient on an emergency basis in the office after a playground accident. The physician sends the patient to the emergency room for observation for head trauma (920, Contusion of face, scalp, and neck except eye[s]). Several hours later, the pediatrician goes to the emergency department to examine the child, who has improved and can be discharged. Report 9920x for the office visit and ED code, upcoding to account for the work of both sites of service.

Observation status generally is restricted to less than 24 hours. If a patient is admitted to observation status on one calendar day and discharged from it on the next calendar day, you should use specific initial and discharge observation codes. If the patient stays in observation status in the emergency department for less than 24 hours but for two calendar days, whether this is in a hospital unit or observation unit, bill the observation discharge code on the second day.

Hospital unit: For example, a pediatrician admits a 5-year-old for observation with a high fever (780.6, Fever) at 5:30 p.m. The patient stays in the hospital overnight and is discharged the next afternoon. You should report an initial observation code (99218-99220) for the first day and the discharge observation code (99217) for the second day.

Observation unit: In another example, a pediatrician decides to admit a 7-year-old to observation for right lower quadrant abdominal pain (789.03, Other symptoms involving abdomen and pelvis; abdominal pain, right lower quadrant) after examining the child in the office. The patient goes to the observation unit in the hospital at 3:00 p.m., where he has blood and urine tests to rule out appendicitis. Due to inconclusive results and continued pain, the pediatrician decides the child should remain in the unit overnight. The next morning, the child is much improved, and blood and urine tests are normal. The pediatrician discharges the patient. For this case, you should report the initial observation code (99218-99220) for the first day, incorporating the work done in the office to upcode the level of service. For the second day, report discharge from observation (99217).

Emergency department: The emergency department occasionally serves as a two-day observation site of service. For example, a pediatrician visits a 16-year-old with persistent wheezing (786.07, Symptoms involving respiratory system and other chest symptoms; dyspnea and respiratory abnormalities, wheezing) in the emergency room at 10:30 a.m. The patient remains in the emergency department throughout the day. The pediatrician decides that he is not ready to leave that evening. The next morning, the patient has improved and is ready to be released. For the first day, report the initial observation code (99218-99220) and the observation discharge code 99217 for the second day.

In the above examples, supporting documentation is important, Tuck says. Dictate a separate history and physical on the second day. "If you don't do that, some companies will want to make day two a subsequent hospital day," Tuck says.

Observation to admission: At times, the patient moves from observation status to inpatient status, requiring a combination of two code sets. For example, a pediatrician admits an infant with fever (780.6) and wheezing (786.07) for observation at 5:30 p.m. The next morning, the child has not improved and requires oxygen. The pediatrician admits the patient to the inpatient unit of the hospital. On the third day, the child has improved and can be discharged. You should report observation care (99218-99220) for the first day, a hospital admission code (99221-99223) for the second day and a hospital discharge code (99238-99239) for the third.