Pediatric Coding Alert

When a child is dehydrated due to gastroenteritis, many pediatricians send the patient to the hospital for intravenous hydration. They reason that it is less and trouble to treat the problem in this manner than to treat it themselves. What they don't realize, however, is that hydration treatment in the office, when coded properly, pays well enough to make it worth the time. Furthermore, the parent and child prefer to avoid the hospital, making in-office hydration good for customer satisfaction as well as reimbursement. But, you need to know the correct codes.
 
For the first hour, use 90780 (intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). Bill additional hours with add-on code 90781 ( each additional hour, up to eight hours [list separately in addition to code for primary procedure]). Pediatricians can usually accomplish intravenous hydration in about one to three hours.

All cases of gastroenteritis will require a separately identifiable E/M visit to assess the cause of the vomiting and dehydration, says Richard H. Tuck, MD, FAAP, at PrimeCare Pediatrics in Zanesville, Ohio. Payment, however, may depend on the plan's policies.
 
For example, a patient has straightforward, infectious gastroenteritis, probably caused by a virus. Use the E/M code (99212-99215) with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), and 90780 for hydration. Or a patient has food poisoning; bill the E/M code with modifier -25 and 90780. Or the patient has pneumonia with secondary vomiting and fever and dehydration. Use the E/M code with modifier -25, 90780, and Rocephin (J0696).
 
"Technically, the pediatrician can bill an E/M as well, if performing a separately identifiable service," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "First, you examine the child, and then you decide on the treatment."
 
But, reimbursement for the E/M is carrier-specific, Callaway says. Some payers, whenever they receive a claim that has a procedure and an E/M, always query the E/M, she says. "They expect you to prove that you did something else." Documentation is crucial: Write a good E/M note and make sure it is in a separate paragraph from the note about the hydration.
 
The need for modifier -25 is also carrier-specific, Callaway says. "Just as the carrier will decide whether to pay for the E/M in addition to the procedure, the payer will decide whether you need modifier -25 on the E/M."

Do not use prolonged services codes (99354-99355) with intravenous infusion codes, as 90780 and 90781 are by definition time-based. Some pediatricians might use prolonged services codes instead of the intravenous infusion codes, but these pediatricians would have to stay with the child throughout the infusion.
 
For 90780 and 90781, the physician must supervise the case but not necessarily be face-to-face with the patient. Prolonged services codes require face-to-face contact for that reason, they pay better than intravenous infusion codes. But, many private payers don't recognize prolonged services, so you should use the intravenous infusion codes instead.

Sometimes, even after office hydration, the pediatrician decides to admit the child. For example, a patient with diabetes comes to the office dehydrated after a bout of gastroenteritis, and the pediatrician attempts office hydration coding 558.9 (other and unspecified noninfectious gastroenteritis and colitis). However, after several hours, the child has persistent vomiting requiring admission.
 
In this scenario you can still bill for the in-office hydration, says Melanie Davies, CPC, CPC-H, compliance manager for University Health Associates in Morgantown, W.Va. "The physician time and supplies for the hydration are paid separately," Davies says. Bill the hospital care code (99221-99223), not the outpatient E/M service. Include the work you did in the office when selecting the level of admission code. As long as you include your notes for the office hydration and evaluation, you can ethically use them to upcode the hospital admission, Davies says.
 
Whether the child is subsequently admitted has no bearing on whether you can bill the 90780 performed in the office, Callaway says. "Billable services are billable whether you admit the patient or not," she explains.

If done in a hospital setting, 90780 is not billable, Callaway explains, because of the "under direct supervision" verbiage in the code definition. Medicare rules, picked up by most private payers, do not allow such procedures  to be billed when the site of service is inpatient, because the payers assume that a technician, not a physician, will perform the service. The fee for the hydration is tied to the facility fee.