Pediatric Coding Alert

The most commonly used pediatric codes are E/M services, and when pediatricians lose money for extra time spent on these services, the loss can be big. Because the E/M codes are not age-specific, there is no easy way to reflect the excessive time young patients can consume. But there are coding solutions to this problem.
Prolonged Services  
Outpatient prolonged services codes (99354-99355) are used in addition to an office visit code when the pediatrician provides face-to-face patient services. The time attributed to these codes need not be continuous but must be the same day as the E/M encounter. Because these codes require that time be monitored carefully, document "time in" whenever seeing a patient whose encounter might be protracted, e.g., a patient who is wheezing.
 
The descriptor for CPT 99354 (prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service) specifies first hour of prolonged services, but this is misleading. Rather, this code is for 30 to 74 minutes of prolonged services -- less than 30 minutes is part of the base E/M service.
 
Use the time indicator in CPT Codes for the office visit to calculate when to start the clock for prolonged services. For example, an infant needs treatment for bronchiolitis. He is in an exam room -- receiving nebulizer treatments and being monitored for respiratory function -- for a total of 120 minutes, 85 of which the pediatrician is in constant attendance. Bill 99215 (office or other outpatient visit for the evaluation and management of an established patient) for the office visit and 99354 for prolonged services. The time indicator for 99215 is 40 minutes face-to-face. The total time spent on the encounter was 85 minutes, so 45 minutes qualifies for prolonged services.
 
If a total of 65 minutes had been spent, 99215 should be reported alone because only 25 extra minutes were required -- not enough to bill prolonged services.
 
Documentation Issues   
When providing documentation for prolonged services, take care to track not only the time but the services provided, says A.D. Jacobson, MD, FAAP, chairman of the AAP Section on Administration and Practice Management and a practicing pediatrician in Phoenix. "Document how long you spend with the patient in the chart, and note exactly what you do during that time," he says.
 
The pediatrician need not be in constant attendance to bill the prolonged services codes, Jacobson says: "You might leave the room to see a child with an earache, or another kind of brief visit." But track the time in and out so you [...]