Pediatric Coding Alert

To reap the full benefits of in-office hydration therapy, such as increased patient convenience and revenue, follow six steps to ensure that you claim all permissible services.

Report intravenous (IV) infusion for dehydration based on the length of the infusion. For the first hour, you should use 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour), says Jeanne Smith, reimbursement specialist for Madrona Medical Group, a large multispecialty group, which includes 14 pediatricians, in Bellingham, Wash. Bill subsequent hours with +90781 ( each additional hour; up to eight [8] hours [list separately in addition to code for primary procedure]). "Code 90781 is an add-on code and therefore can never be billed alone," Smith points out. When the infusion lasts more than an hour but less than a full additional hour, append modifier -52 (Reduced services) to 90781 to indicate that the time beyond the first hour was less than one hour, according to CPT Assistant.

For instance, a parent brings a child who has vomiting (787.03), a fever (780.6 ) and dehydration (276.5) into a pediatrician's office. After evaluating the patient, the doctor decides to treat the child's dehydration in the office. The total documented duration of the infusion is one and a half hours.

For the first hour of infusion, report 90780. For the additional 30 minutes, assign 90781-52.

The infusion codes are for performing the service only, CPT Assistant states. They do not include the physician's evaluation of the patient prior to providing hydration. If the physician determines that the patient needs hydration therapy the same day as the patient encounter, bill both the E/M code (appended with modifier -25, Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and the infusion codes (90780-90781), Smith says.

For example, a patient presents to a pediatrician's office with diarrhea (787.91), nausea with vomiting (787.01) and abdominal pain (789.0x). The pediatrician evaluates the patient's symptoms and diagnoses infectious gastroenteritis (009.0). The patient is dehydrated from the inability to keep fluids down, so the pediatrician administers an IV infusion for one hour.

The pediatrician examines the patient's symptoms to determine the proper course of treatment, meaning he or she provides a significant, separate E/M service. Bill the appropriate-level office visit (99201-99205, New patient; 99211-99215, Established patient), based on the level of history, examination and medical decision-making documented. Append the E/M code with modifier -25 to show that the pediatrician performed a separately identifiable service from the infusion. For the infusion, report 90780.

Link 9921x to 009.0, and 90780 to 276.5. Although CPT does not require separate diagnoses to bill both procedures, different diagnoses help payers understand that the services are provided for different reasons and are, therefore, separately reimbursable.

Although carriers may differ in accepting modifier -25, "Most insurance carriers reimburse for both the office visit and the infusion, provided the modifier is appended to the E/M code," Smith says. When a carrier denies a charge, send an appeal letter to the insurance company with the chart notes attached. In this case, the carrier usually covers the services, she says.

Clear operative notes should show the payer that the services are separate, so document the office evaluation and the infusion separately. Write a good E/M note in a separate paragraph from the note concerning the infusion.

Documenting separate services is also crucial if the physician is billing for hydration in addition to other services, such as chemotherapy. For instance, a patient presents for a scheduled chemotherapy treatment. Following the chemotherapy, the patient is dehydrated, which the pediatrician treats with a saline solution infusion.

In this case, you should report the chemotherapy and the infusion. The pediatrician is giving the saline solution for hydration, not as a vehicle to deliver a different drug, such as a chemotherapy drug, Smith explains. For the chemotherapy treatment, report the appropriate chemotherapy administration code (96400-96549), such as 96410 (Chemotherapy administration, intravenous; infusion technique, up to one hour).

For the pediatrician's evaluation of the patient, which led to the infusion, assign an office visit code (99211-99215) appended with modifier -25. For the infusion administration for hydration, use the infusion codes (90780-90781). "Clearly document that the chemotherapy and the hydration therapy were administered sequentially or as separate procedures," Smith says. In summary, report the example 9921x-25, 96410, 90780.

The infusion codes include the supplies but not the infused substance. "The supplies, such as needles and tubing, are bundled into the infusion administration codes," Smith says. Bill the infused drugs separately with the appropriate HCPCS level II J codes. For instance in the previous chemotherapy example, you should also report any infused agents, such as J9370 (Vincristine sulfate, 1 mg) for the chemotherapy drug and J7042 (5% dextrose/normal saline [500 ml = 1 unit]) or J7120 (Ringer's lactate infusion, up to 1,000 cc) for the saline solution.

The same rules apply for reporting the drugs when an antibiotic is administered intravenously. For instance, a patient has pneumonia (486) with secondary vomiting, fever and dehydration. The pediatrician administers IV infusion with an antibiotic to treat the pneumonia. Report the office visit (99201-99215), the infusion (90780) and the antibiotic (e.g., Rocephin, J0696, Injection, ceftriaxone sodium, per 250 mg). The infusion includes the supplies but not the physician's initial patient assessment or the cost of the infused substance.

Do not report prolonged services (99354-99357) in addition to the infusion codes (90780-90781) because prolonged services codes are time-based, CPT Assistant states. The infusion codes require the physician's presence in the office during the infusion but not in the room where the infusion is administered, Smith says. The physician must supervise the case but does not have to remain physically present throughout the infusion. In contrast, the prolonged services codes require direct (face-to-face) patient contact. Therefore, reporting these codes together is inappropriate.

If a pediatrician decides to report prolonged services instead of the infusion procedure, he must stay with the patient the entire time. Many private payers, however, do not accept the prolonged services codes, so you should use the infusion codes instead.

Sometimes a pediatrician admits a patient to the hospital after in-office infusion. CPT coding convention permits billing one E/M service per day. "Carriers won't pay for an office evaluation and admission to hospital on the same day," says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J. "Use the hospital admit codes (99221-99223, Initial hospital care, per day ) when admitting from your office." Combine the work performed in the office in the hospital admission code.

For instance, a patient with diabetes comes to the office dehydrated after a bout of gastroenteritis (558.9, Other and unspecified noninfectious gastroenteritis and colitis). The pediatrician attempts in-office hydration. After several hours, the child still has persistent vomiting, and the pediatrician admits him to the hospital.

For the physician's E/M work on that day, assign a hospital admission code (99221-99223). Do not report an office visit. Instead, include the history, examination and medical decision-making performed in the office to select a higher-level hospital admit code. In addition, report the infusion and any infused substances. The physician provided these services, and they are billable regardless of whether the hydration succeeds.

Infusion provided in the hospital is not a billable service, Smith says. Payers assume that when the patient receives hydration therapy in a hospital, the hospital staff, not the pediatrician, performs the service. The fees for the administration, the drugs and the supplies are hospital expenses, and the pediatrician should not bill for them.

For instance, consider the previous example of the diabetes patient who is subsequently admitted to the hospital following in-office hydration therapy. On day two, the pediatrician visits the patient and orders infusion for the patient's continued dehydration. The doctor should bill for his services provided on day one as described above. For the E/M on day two, he reports subsequent hospital care (99231-99233). He does not charge for the in-hospital infusion because the fee is tied to the hospital, not the pediatrician.