Pediatric Coding Alert

Question: A patient reported to our pediatrician with congestion, wheezing, and coughing. In addition to billing for an evaluation and management (E/M) service, we also billed for pulse oximetry, two nebulizer treatments, and albuterol. Because our provider could not get the pulse ox up, she also tried deep nasal suction (we just suction the nose - we don't go into the nasotracheal region), but we have been told we cannot bill for this. So, how should we bill for this encounter?

Ohio Subscriber

Answer: You could actually code this scenario in two different ways depending on the severity of the patient's condition. But either way you code the encounter, the nasal suction procedure you describe would be bundled into the E/M service as it is regarded as a noninvasive procedure. The pulse oximetry may also be bundled, too, depending on which coding route you decide to take.

If the provider determined that the patient was critically ill (for example, if the patient was in acute respiratory distress, suffering from hypoxia, was tachypnic, or suffering an asthma exacerbation), it is possible that the level of care could rise to 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes).

Here, you would have to document that the patient's condition was life-threatening and that your provider's decision making was at a high enough level to "prevent further life-threatening deterioration of the patient's condition" according to CPT®. You would also have to document the amount of time your provider spent in patient care, as 99291 and its add-on code +99292 (... each additional 30 minutes) are time-based.

Using this way of coding the encounter, you would not be able to bill 94760 (Noninvasive ear or pulse oximetry for oxygen saturation; single determination) or 94761 (Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations (eg, during exercise)), as these pulse oximetry procedures are considered bundled into the critical care.

You can, however, bill for the nebulizer treatment with 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction ... with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device)  along with J7613 (Albuterol, inhalation solution, FDA-approved final product, non-compounded, administered through DME, unit dose, 1 mg) for the Albuterol.

The other way to document this scenario would be to code it as a level-five E/M service such as 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Here, again, you would have to document that your pediatrician used high-complexity medical decision making along with a comprehensive history and/or a comprehensive exam. You will also need to show that the patient was suffering from a moderate- to high-severity medical condition.

In this situation, you can then go ahead and bill for the nebulizer and Albuterol as you would with 99291, but this time you can also bill for the pulse oximetry. You would also add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99215 to indicate your pediatrician performed separate services.