Pediatric Coding Alert

Sheryl Cilento, office manager for Liberty Child and Adolescent Health Services, an 11-pediatrician practice in Jersey City, NJ, wants to know how to use CPT Codes to manage babies and children who are being cared for at home. Often a newborn is discharged and there is a visiting nurse ordered by the home health agency, says Cilento. Or a child might have gastroenteritis and needs diet and medication to be supervised, or sometimes there is a case of juvenile diabetes. The pediatrician always has to be involved. There is an inordinate amount of paperwork -- orders to fill, reorder forms, often on a monthly basis. This is a busy urban practice with many children on managed Medicaid. Is there any way that Cilentos practice can bill for the time it spends overseeing the care of patients who are being treated at home?

The answer is a resounding yes. There are care plan oversight codes, as of CPT 98, for patients under the care of home health agencies, hospice patients, and nursing facility patients. All of these codes must be used only when the pediatrician is supervising care others are providing to the child, not when the pediatrician does face-to-face care, as in home visits. (Note: For more information on home-visit coding see cover article in March 1998 issue of PCA).

There are two basic aspects of these oversight codes which are new for 1998. One is that they are broken down into two units: 15 to 29 minutes and 30 minutes and above. In CPT 97, the smallest unit was 30 minutes. This means that you can now bill for as little as 15 minutes a month spent overseeing a case. That 15 minutes can be cumulative, so that you may spend 5 minutes one day and 10 minutes another day on the case. The key is that you must keep track of your time over a month, and file one bill a month for your care plan oversight services.

Hospice and Nursing Facility Care Plans

The other new aspect of these codes is the addition of hospice and nursing facility care plans. While such cases are not common in pediatrics, they are, unfortunately, getting more frequent, says Peter Rappo, MD, FAAP, chairperson of the AAP Committee on Ambulatory and Practice Medicine. Children with muscular dystrophies are living longer, and need to be in nursing facilities, says Rappo, who practices in Brockton, MA. And we do have kids who are terminally ill. Rappo notes that AIDS is increasing among children. Also, pediatric patients with terminal malignancies and renal conditions are often in hospices.

Pediatric nursing homes tend to be centralized, the physician adds. And if a pediatric practice is near one, they will probably send their patients to it.

So, even if pediatric hospice and nursing facility cases are rare, the physicians supervising them will need to know how to use these new codes properly in order to be adequately compensated for their time.

The code for care plan oversight of a hospice patient is 99377 for 15-29 minutes and 99378 for 30 minutes or more. The code for care plan oversight of a nursing facility patient is 99379 for 15-29 minutes and 99380 for 30 minutes or more.

Home Health Agencies

Rappo acknowledges that home health agencies are usually much more common in pediatric care. And many will be acute, not chronic. For example, a child may step on a rusty nail and develop Pseudomonas osteomyelitis. After intravenous antibiotic therapy is initiated in the hospital, the child is sent home, where it is continued. The pediatrician orders the treatment at home, has to talk to the home health agency about the progress, and keep track of how well the family is doing. The home health agency sends the pediatrician an unbelievable amount of paperwork, explains Rappo.

The care plan oversight services codes for use when patients are under the care of home health agencies but are supervised by the pediatrician cover the following:

99374: Physician supervision of a patient under care of home health agency (patient not present) requiring complex and multidisciplinary care modalities involving regular physician development and/or revision of care plans, review of subsequent reports of patient status, review of laboratory and other studies, communication (including telephone calls) with other health care professionals involved in patients care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 15-29 minutes.

99375: Is the same as 99374, except that it is for 30 minutes or more per calendar month. For pediatricians, the smaller unit of 15 minutes is useful, since they are more likely to use these time blocks.

Is Billing Worth It?

The big problem for pediatricians is going to be figuring out how to keep track of their time, says Rappo. You should concentrate your billing efforts on those children who take up a lot of your time, he advises. A child whos home on a ventilator will take a lot of time, and you wont have any trouble tracking it, he says. But what about a child who is getting rehydrated at home? You may spend 15 minutes doing care oversight in a given month. But the issue is one of labor intensity, as Rappo puts it. You have to decide which is more work. If you spend more time documenting than you spend performing care oversight, is it worth billing for it? So, you have to have a mechanism capturing your time to make billing worth it, says Rappo.

Why Not Telephone Codes Instead?

Instead of keeping track of minutes, wouldnt it be easier just to use telephone codes? No, states Rappo. We know intuitively that telephone management codes are not usually honored by insurance carriers, he explains. These care plan oversight codes are more likely to be reimbursed.
And Rappo strongly believes that pediatricians should be using care oversight codes. A lot of what we do over the phone is not billed, he says. Lawyers have this all figured out; they bill for everything. And they invest a great deal of time in figuring out how to do so. But theyre not usually doing three things at a time, as Rappo points out pediatricians often are.

Were going to need some help from our office staff to do this, Rappo says of documenting and billing.