Pediatric Coding Alert

Highlight the phrase "in addition to basic service."

Pediatricians don't always see patients during scheduled office visits, which means you probably see walk-in patients almost every week. Although some practices immediately stamp a 99058 code on all walk-in claims, you should avoid adding this code to your visit unless you can prove that the patient's visit is truly emergent.

Office Emergency Points to 99058

Think "emergency" and "interruption" when considering whether to include 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) on a claim.

"It needs to truly be an emergent or urgent problem that disrupts the physician's schedule - not lunch, but their schedule," says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "It can apply to walk-ins if they have a triage assessment and have an acute problem that needs to be worked up immediately and they are seen by a doctor as soon as possible; but it doesn't apply in a uniform way to walk-ins," Tuck says. He notes that reviewers have seen 99058 linked to ICD-9 codes for pharyngitis, upper respiratory infections, and other conditions that are typically considered non-emergent.

"In our office we have a nurse who does a triage assessment on every child," Tuck says. "She'll take a history and if the child has a history that's worrisome or appears ill, she brings them right back and when we come out of the next room seeing a patient, she's standing there waiting and sends us in there immediately."

Tip: Cases that merit 99058 are urgent care situations that disrupt the office schedule, such as a child with asthma who is experiencing active wheezing and shortness of breath (493.02, Extrinsic asthma; with [acute] exacerbation).The patient's parent could bring the child himself, or another physician office could call saying the patient needs to be seen right away. Be sure the pediatrician adequately documents the situation, however, before submitting 99058 -- payers want to know that the physician treated the patient for an emergent problem, disrupting their schedule.

Remember to Include E/M Codes

At first glance, 99058 seems comprehensive enough to stand on its own. Take a closer look, however, and the phrase "in addition to basic service" is your clue that more codes are needed.

CPT doesn't designate the status with a plus sign, but the code technically is considered add-on. Therefore, you can only report it in conjunction with the appropriate E/M code.

Some payers, including Medicare, do not reimburse for the after-hours codes -- but others do. Reimbursement rates might not be high, but every little bit adds up. You can also use the fact that some payers are reimbursing you for this code to help negotiate for payment from non-paying insurers.