Pediatric Coding Alert

Sometimes a pediatrician must go to the emergency room to see a childusually, this happens after the office is closed. If the child is not admitted to the hospital, how should you code the visit? asks Gail Schonfeld, MD, of East End Pediatrics, a four-pediatrician practice in East Hampton, NY.

The case involved a three-week-old baby who was not East End Pediatrics patient. The baby had a perirectal abscess, and the ED physician wanted the pediatrician to examine the child. The situation occurred during office hours, which meant a pediatrician had to leave the office schedule for the time-consuming care of the baby, who was eventually sent home.

Consultation Codes

East End Pediatrics used the outpatient consultation codes, which is appropriate in this case. These codes CPT 99241 to 99245 are for consultations provided in the physicians office or in an outpatient or other ambulatory facility, including hospital observation services, home services, domiciliary, rest home, custodial care, or emergency department.

To use these codes, your services must be requested by another physician or other appropriate source. The request cannot come from a patient or family. East End Pediatrics used 99245. The practice hasnt been paid yet because the Medicaid HMO that covers the babys care claims that only care provided in the HMOs clinic will be covered. The practice is in the process of appealing the denial, says Schonfeld.

Regardless of similar complications, these codes are appropriate because the pediatrician was responding to the request of another physician to provide an expert opinion. He was not treating the practices patient.

Emergency Department Codes

We talked to two billing experts about how they would handle such cases. Both suggested the use of the emergency department services codes: 99281-99285but only when a pediatrician meets a child who is normally their patient in the ED, and are not requested to be there by the ED physician.

We bill for our services, and emergency services bills for the room, says Wendy Buemi, RN, office manager for West Central Pediatrics, a two-pediatrician practice in Delaware, OH. Usually, this happens at night, she says. Our practice is right next to the hospital, so its just as easy for the parent to bring the child here during the day. From 5:00 to 9:00 at night, the office is closed, but the building is open, so the pediatrician can meet the child in the office, says Buemi. We use after-hours codes (99050-99052) for that time, she says. After 9:00 at night, the building is closed, so the child goes to the emergency room; that is when the pediatrician might be summoned.

At Childrens Medical Group, a 13-pediatrician practice in Mobile, AL, only 99284 is used for these situations, says Jan Taylor, assistant office manager. Why only 99284, which is the fourth-level code for emergency department services? It works for us, she says. We get paid on it, no questions asked. The practice uses 99284 regardless of the documentation. However, this would be viewed very unfavorably in a Medicare audit. We dont do any Medicare, notes Taylor. If we have an ED sheet that says the pediatrician has been there, thats the code we use. The only time it doesnt work, says Taylor, is when the child is admitted. Then, you would use the initial hospital services codes (99221 - 99223); you could not use one of these as well as an emergency department services code on the same day.

Note: We recommend that you proceed with caution if you choose to use higher level codes without sufficient documentation. The level of services chosen should be based on the documented services provided.

The emergency department codes are only to be used when the pediatrician is the physician who cares for the patient in the ED. If the ED physician calls the pediatrician in, you should use a consultation code.

99281: ED visit requiring a problem-focused history, a problem-focused examination, and straightforward medical decision-making. Problems are self-limited or minor. 99282: ED visit requiring an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity. Problems are of low to moderate severity. 99283: ED visit requiring an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity. Problems are of moderate severity. 99284: ED visit requiring a detailed history, a detailed examination, and medical decision-making of moderate complexity. The problems are usually of high severity, requiring urgent evaluation, but do not pose an immediate significant threat to life or physiologic function. 99285: ED visit requiring, within the constraints of the patients clinical condition, a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Presenting problems are of high severity and pose an immediate significant threat to life or physiologic function.