Primary Care Coding Alert

The latest National Correct Coding Initiative (NCCI)  edits confirm a coding guideline you probably know: Insurers won't cover two same-day E/M services - even if one is for an office visit and the other is for inpatient daily critical care.

Critical Care Includes More Than 75 Services

NCCI version 10.0, effective Jan. 1, bundles numerous E/M codes with revised codes for pediatric critical care (99293, Initial inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child; and 99294, Subsequent inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child) and neonatal critical care (99295, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less; and 99296, Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less).
 
"When you use 99293-99296, NCCI indicates that you cannot concurrently bill many outpatient and inpatient codes," says A. Clinton MacKinney, MD, MS, the American Academy of Family Physicians representative to the AMA CPT advisory committee. Payers that follow Medicare's edits now include the following services with pediatric and neonatal critical care codes:

  office visits - 99201-99215
  observation discharge - 99217
  observation care - 99218-99220
  hospital care - 99221-99233
  admission and discharge services - 99234-99236
  hospital discharge services - 99238-99239
  consultations - 99241-99275
  emergency department services - 99281-99285
  pediatric critical care patient transport - 99289
  critical care services - 99291-99292
  nursing facility services - 99301-99316
  domiciliary, rest home, or custodial care services
   - 99321-99333
  home services - 99341-99350
  newborn care - 99431-99435.

Translation: If your FP provides any of the above services on the same day he performs pediatric or neonatal critical care, you should bill only 99293-99296. The edits contain a "0" modifier. So, you may not use a modifier, such as -59 (Distinct procedural service) to override the bundle.
 
But you may report an included same-day E/M when physicians in separate practices or specialties perform the services. For instance, after an FP admits a normal newborn to the hospital, the neonate develops sepsis (771.81, Infections specific to the perinatal period; septicemia [sepsis] of newborn). The FP turns over the infant's care to a neonatologist who admits the patient to neonatal critical care.
 
In this case, because different specialists provide the E/Ms, each physician should report his or her services, says Richard A. Molteni, MD, FAAP, a neonatologist at Children's Hospital and Regional Medical Center in Seattle. The FP would bill for the history and examination (99431, History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing-room deliveries]). The neonatologist would report initial neonatal critical care (99295).

Global Code Covers Multiple Same-Day E/Ms

But when the same FP provides an E/M service that later turns into inpatient pediatric or neonatal critical care services, you should use only 99293-99296.
 
Here's an illustration: A mother brings her 11-month-old son who has a high fever to an FP's office. The physician admits the child to the hospital due to a fever of unknown origin (780.6). At the hospital, the child becomes critically ill, and the FP provides critical care services.
 
In this case, you should report initial pediatric critical care (99293) for the FP's E/M services. If a physician performs outpatient and critical care services on the same day with identical diagnoses, the global charge (99293-99296) includes the initial E/M, Molteni says.

NCCI Follows CPT

Don't lose sleep over these new edits. The critical care bundle (99291-99292 with 99293-99296) comes straight from CPT 2004's revised inpatient neonatal and pediatric critical care services notes: "If the same physician provides critical care services for a neonatal or pediatric patient in both the outpatient and inpatient settings on the same day, report only the appropriate neonatal or pediatric critical care code (99293-99296) for all critical care services provided on that day." That means 99293-99296 are global codes that include all the day's critical care procedures, Molteni says.
 
But NCCI 10.0 takes CPT one step further and includes outpatient, noncritical services with neonatal and pediatric critical care. The bundle reaffirms a billing basic: Insurers won't accept two same-day E/Ms containing identical diagnoses from the same physician. In other words, 99293-99296 are per-diem (per-day) codes, MacKinney says.
 
The edits, however, don't permit any exceptions to the rule. Usually, you may report two same-day E/Ms with different diagnoses. In this instance, you would append modifier -59 to the second E/M to designate the service as distinct from the first E/M. But NCCI 10.0 doesn't allow this distinction.