Pediatric Coding Alert

Look for these 3 E/M-related billing possibilities

You can improve your catheterization encounter pay if you know whether the visit qualifies for time-based, prolonged services, or adjunct service billing.

After reviewing the following pediatric urinary catheterization scenario, one coding expert found three legitimate ways to add over $200 to a claim containing 51701 (Insertion of non-indwelling bladder catheter [e.g., straight catheterization for residual urine]) and CPT 99212 (Office or other outpatient visit for an established patient ...).

The case: A pediatrician saw an older child at 10:30 p.m. for acute urinary retention due to perineal pain after a straddle injury. The pediatrician spends over an hour face-to-face with the patient. The insurer paid only $45 for the established patient office visit (99212) and denied the catheterization (51701).

You should check the note for information on whether counseling and/or coordination of care dominate the visit. "If they do, bill the visit based on time," says Michael A. Ferragamo Jr., MD, FACS, clinical assistant professor of urology for the Health Science Center at the State University of New York in Stony Brook.

In the straddle-injury example, the pediatrician spends over an hour with the patient. If she spends the majority of the visit on counseling and case discussion, she should report 99215 (... physicians typically spend 40 minutes face-to-face with the patient and/or family) for an established patient office visit, instead of 99212 (... physicians typically spend 10 minutes face-to-face with the patient and/or family). "Documentation must include the total time spent, counseling time and topic(s) discussed," Ferragamo says. The level-five visit would account for 40 face-to-face minutes and add about $80 (estimated difference between 99215 and 99212) to the claim.

You may spend more time than usual on E/M services in which you decide the patient requires urinary catheterization. These cases often involve complex decision-making and choosing between several diagnoses, says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio. So, the visit may qualify for prolonged services in addition to or instead of time-based billing.

Suppose in the straddle-injury scenario the pediatrician's documentation supports 99212, but the visit requires her to spend 60 minutes on the E/M service. For the additional face-to-face time without procedures, she could bill an extended care code, Ferragamo says.

Code 99212 would account for 10 minutes. She could also report +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]) because she spends 30 minutes more than CPT's 99212 threshold (10 minutes), Tuck says. Billing 99354 would add over $97 to her reported E/M service pay.

Urine catheterization encounters may occur after office hours or interrupt scheduled appointments. In these cases, you should report an after-hours code such as 99052 (Services requested between 10:00 p.m. and 8:00 a.m. in addition to basic service) or emergency treatment (99058, Office services provided on an emergency basis).

The pediatrician who treated the straddle-injury patient came in after-hours to provide the service and procedure. For the after-hours service, she should bill 99052, Ferragamo says. If an insurer doesn't recognize the added service, remind the representative of the money saved treating the patient in the office rather than in the emergency department.

Revenue: With proper documentation, diagnoses, E/M modifier and related services, our real-world pediatrician could claim over $240 for treating the after-hours patient and performing catheterization. (Total is based on Medicare allowables of $81.40 for 51701, $37.15 for 99212, $96.71 for 99354 and an estimate of $25 for 99052.)