Pediatric Coding Alert
Treat Partnering Pediatricians' Visits as One
Colorado Subscriber
Answer: Even though two pediatricians performed the services, the physicians are part of one practice and likely share the same tax identification number. Therefore, the insurer probably wouldn't recognize that different doctors performed the office visits and would reject two same-day E/Ms. The only time that a payer might cover a second same-day E/M is if the visits contain separate diagnoses.
Because the diagnosis (464.4, Croup; or 786.2 , Cough) for both visits is the same, you should combine the services and submit one code for the day. If each visit is a 99213 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 15 minutes face-to-face with the patient and/or family) (performed twice during the day), you may code a single 99214 (... physicians typically spend 25 minutes face-to-face with the patient and/or family) for the day.
On the other hand, different-level visits may be harder to code. For instance, if one E/M is a level-four (99214) and the other is a level-five (99215, ... physicians typically spend 40 minutes face-to-face with the patient and/or family), you may need to consider prolonged service code +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]) in addition to 99215. To use the initial prolonged service code, you need to spend 30 minutes more than the 40 minutes 99215 includes.
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