Pediatric Coding Alert

Question: Our pediatrician saw a patient in his office for an emergency—a patient was bleeding from the arm and the doctor had to apply a tourniquet and then stitch up the deep laceration. Can we report emergency department E/M codes to report the visit?

Answer: You cannot report emergency department E/M codes when handling an emergency situation in your clinician’s office. You need to report an appropriate office E/M code (such as 99201-99205 for new patient or 99211-99215 for established patients) for the visit. The emergency department E/M codes are intended to be reported only for E/M services in an emergency department, which CPT® defines as “an organized hospital-based facility for the provision of unscheduled episodic services to patients who present for immediate medical attention. The facility must be available 24 hours a day.”

If your pediatrician’s routine in handling other patients for the day was disrupted due to the emergency visit that your clinician undertook, you can report 99058 (Service[s] provided on an emergency basis in the office, which disrupts other scheduled office services, in addition to basic service) along with the E/M code that you are reporting for the visit. Note, however, that some Medicaid contractors and many other payers consider code 99058 to be a service bundled into the E/M code and will not separately pay for it. 

However, in the event that your pediatrician performs an emergency visit that fulfills the requirements for critical care, you can report a critical care code for the situation. In this case, you will have to report 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and the add-on code +99292 (…each additional 30 minutes [List separately in addition to code for primary service]) depending on the time spent by your clinician in providing the service. The critical care codes are not restricted to a particular place of service. As CPT® notes, “Critical care is usually, but not always, given in a critical care area, such as the coronary care unit, intensive care unit, pediatric intensive care unit, respiratory care unit, or the emergency care facility.”

Coding tip: If you are reporting critical care services codes, 99291-99292, you should not additionally report an E/M code for the same time spent with the patient. Per CPT®, “Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.” Thus, the same period of time cannot be counted toward both critical care and other E/M services.