Pediatric Coding Alert

When coding for nebulizer encounters, how do you factor in the time the pediatrician spends? If the patient is there for three hours and youre monitoring your time, then you can code for prolonged services, explains A.D. Jacobson, MD, FAAP. How closely do you need to monitor your time? I dont think its practical to clock in and out, he responds. Prolonged services codes are 99354 for the first 30 to 75 minutes (over and above the evaluation and management [E/M] services code that youre adding to) and 99355 for each additional 30 minutes. Its significant that CPT even uses the asthmatic example in the descriptor of these codesa fairly unusual event. The descriptor for 99354 is: 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).

So in the case of the child who requires multiple treatments, you would code the office visit (99215 if you are using the prolonged services codes), the prolonged services codes that are applicable (CPT 99354 and 99355), the nebulizer treatments (94640 x the number of treatments), the spirometry (94010 x the number of readings), and the pulse oximetry (94760 x the number of treatments). You would also code 97535 if you are doing teaching.

Finally, you can bill for an E/M visit with 94640 or 94664 or 94665, the American Medical Association (AMA) notes. As stated in the introductory notes of the pulmonary subsection, if the physician meets the criteria for reporting an E/M code at the same encounter, it is indeed appropriate to report the E/M code in addition to the pulmonary procedures, the AMA says. The AMA suggests appending the modifier -25 to the E/M code to meet certain payer requirements.

Insurance companies realize that the pediatrician is always coming in and out of the room, for example, checking an otitis media patient in between, says Jacobson. This is going to be a big claim, and youll have to file it in hard copy, but insurance companies will pay it, says Jacobson. This is a high-stress thing, he says. Youre trying to keep the child out of the hospital. Every insurance company can see the benefit of that instantly. What we do is send a copy of the pediatricians notes, the time spent, and a note that lets the insurance company know that we saved them an admission, he says. This is a great example of how an insurance company will pay for prolonged services codesif you document what you do, you achieve your goal of keeping the child out of the hospital, and everyone benefits.