Pediatric Coding Alert

Capitalizing on reimbursement for treating bee-venom-triggered anaphylaxis in the office depends on knowing if the service qualifies for critical care codes, and if it doesn't, which codes to use instead. Although some pediatricians and coders think that 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 ( each additional 30 minutes [list separately in addition to code for primary service]) are for hospital use only, you may use these high-paying codes in the office if you follow CPT's guidelines for reporting critical care services, says Diane M. Minard, CPC, pediatrics coding specialist for Dartmouth Hitchcock Medical Center in Lebanon, N.H. The Medicare Physician Fee Schedule, which many private payers use as a guide, pays a geographically unadjusted nonfacility rate of $210.07 for 99291 and $107.79 for 99292. In some instances of anaphylaxis due to bee or wasp venom, the patient's condition may require critical care services. For instance, a child who has an anaphylactic reaction to a bee sting may experience respiratory distress, vascular collapse, shock, urticaria (hives), angioedema and pruritus. If the episode meets the criteria for billing critical care services, using a higher-level office visit code such as CPT 99214 (Office or other outpatient visit for the E/M of an established patient physicians typically spend 25 minutes face-to-face with the patient and/or family) instead of 99291-99292 will cost your practice $130.24. But before you start reporting critical care codes, make sure you know the rules. Critical Care Requires Criteria CPT defines a critical illness or injury as one that impairs one or more vital organ systems creating a high probability of imminent or life-threatening deterioration in the patient's condition. Therefore, if the severe systemic reaction to the insect sting becomes life-threatening and affects one or more of the child's vital organ systems and the pediatrician provides direct medical care, critical care services may apply, Minard says. For instance, the child may have difficulty breathing and go into shock. However, the physician must continue these life-sustaining services for 30 minutes to qualify for 99291. Although the pediatrician does not usually provide these services in the office for an extended period of time, she may perform them until the patient can be transported to a hospital or critical care unit. If the physician attends to a critically ill pediatric child (24 months of age or less) and provides direct critical care in the transportation vehicle for a minimum of 30 minutes, you should report 99289 (Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport) and [...]