Pediatric Coding Alert

With managed care having an increasing say over how long patients can stay in the hospital, one-day hospital treat-ment, especially for observation, is growing more popular. It means a little extra work in terms of coding, however.

Managed care is overseeing all hospital admissions more closely, explains Charles M. Vanchiere, MD, FAAP, CEO of Childrens Clinic of SW Louisiana in Lake Charles. Therefore, pediatricians must be aware of two kinds of short-term inpatient codes: observation or inpatient care services which includes admission and discharge on the same date (the new codes), and hospital observation services (including one revised code). In addition, you may be using the familiar hospital discharge services if the patient was an inpatient instead of on observation status.

If it seems confusing, it is. Vanchiere, who chairs the AAPs RBRVS PAC, prepared a flow chart for PCA with the appropriate slot for each code (see chart below).

What the New Codes Are For

There are three new codes -- CPT 99234 , 99235, and 99236 -- for hospital care services provided to patients who are admitted and discharged on the same date of service. The three codes represent three levels. All three codes apply to either observation status or inpatient care services, and include admission and discharge. You cannot bill any other E/M codes for this day.

99234 is for observation or inpatient hospital care (admission and discharge on same date) requiring a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision-making that is straightforward or of low complexity. The presenting problem is of low severity.

99235 is for observation or inpatient hospital care (admission and discharge on same date) requiring a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. The presenting problem is of moderate severity.

99236 is for observation or inpatient hospital care (admission and discharge on same date) requiring a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. The problem is of high severity.

Frequently, observation status is initiated in the pediatricians office. For example, the child may need to go to the hospital for rehydration, to check for a rebound reaction after inhalation therapy, or for croup. When this occurs, all evaluation and management services provided in conjunction with this are part of the initial observation care. So if you see a patient in your office, and the child is admitted to and discharged from the hospital on the same day -- whether that patient is in observation status or admitted as an inpatient -- you must use one of the new codes: 99234, 99235, or 99236.

Other Observation Codes

What about 99217, 99218, 99219, and 99220?

99217 is a revised code for observation care discharge day management. This code is to be used if a child has been hospitalized for observation for more than one day. It includes the final examination, discussion of the hospital stay, instructions for continuing care, and preparation of discharge records. This code is not to be used when you are using 99234, 99235, or 99236 (admission and discharge on same day).

The initial observation care codes (99218, 99219, and 99220) are for the initiation of observation status. The patient is not discharged on the same day, and these codes are not to be used with 99234, 99235, or 99236.

99218 requires a detailed or comprehensive history, a detailed or comprehensive examination, and medical decision-making that is straightforward or of low complexity. Usually, the problem requiring admission to observation status is of low severity.

99219 requires a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Usually, the problem is of moderate severity.

99220 requires a comprehensive history, a comprehensive examination, and medical decision-making of high complexity. Usually, the problem is of high severity.

As with the observation codes for same-day admissions and discharges, you cannot use separate E/M codes for seeing these patients in your office earlier in the day. Initiation of observation care gets one code per day, regardless of how many times you see the patient in a day. But remember, on the day you discharge them from observation care, use 99217.

Inpatient and Discharge Codes

The other pertinent codes are the straightforward inpatient services and discharge codes. Initial hospital care codes (99221, 99222, 99223) are for the first inpatient encounter. If you admit the child following observation care, you should use these codes for the first inpatient day. On subsequent days of hospitalization, use the subsequent hospital care codes (99231, 99232, 99233).

When you discharge the child from inpatient care, use the discharge day management codes: 99238 for 30 minutes or less, and 99239 for more than 30 minutes.

We talked to two office managers about the ways they are using observation services.

Their local hospital has a 24-hour observation unit, reports Patricia Vogel, office manager for Adirondack Pediatrics, a five-pediatrician, two-nurse practitioner practice in Glens Falls, NY. They use it especially for rehydration or asthmatics, or "anything else the patient doesn't need to be admitted for."

At the Childrens Clinic, a five-pediatrician practice in Tallahassee, FL, observation services are used mainly for cases of gastroenteritis. The kids just need fluids for 23 hours, says Becky Miller, office manager. If they need to be there longer than that, we admit them.

Miller has been using 99218 and 99219 for observation care, and 99217 for discharge from observation care.

(Note: Newborns admitted and discharged on the same date have a special code: 99435.)