Pediatric Coding Alert

Question: Our group of pediatricians evaluates a patient on Monday. The following day, the patient returns for a review of condition by the nurse practitioner (NP), but the NP does not re-evaluate the patient. We usually bill an E/M code for the first day and prolonged services for the second, but I have recently been told that prolonged services must be performed on day one. How should we code the second day?


Arizona Subscriber


Answer: You should use prolonged service codes (99354-99357) as add-on codes “to report the total duration of face-to-face time spent by a physician on a given date,” according to CPT. Although time that you count toward prolonged services need not be continuous, you must perform both sessions on the same date of service as the base E/M service.

In this case, the NP sees the patient on the day after the physician provides the principal E/M service, so the prolonged service codes are not appropriate.

Correct coding for the second day depends on the exact circumstances of the visit. If the NP provides medically necessary services “incident-to” the primary physician, you should bill the follow-up visit as an established patient E/M service (99211-99215).

Insurers define incident-to services as those provided by a nonphysician practitioner that are an integral part of the physician’s personal professional services in the course of a diagnosis or treatment of an injury or illness.

You should report services provided incident-to using the appropriate CPT Codes under the supervising physician’s personal identification number (PIN). The insurer will reimburse your services at 100 percent of the Physician Fee Schedule.

If the NP performs an E/M visit and the physician is not on-site, or the E/M visit does not otherwise meet the criteria of incident-to billing, you should report the E/M visit using the appropriate E/M code and bill it under the NP’s PIN. This may result in a reduction in the reimbursement following Medicare’s lead of reduced payment for NPs at 85 percent of the Medicare payment that your pediatrician would collect.