Pediatric Coding Alert

Question: We recently treated a child with gastroenteritis in the office. The visit required prolonged services because the physician performed intravenous hydration in the office. Ultimately, we had to admit the child, so we billed a hospital admission code. For the prolonged services add-on code, should we file inpatient or outpatient?

Maryland Subscriber
Answer: The place of service was the office, but the add-on codes for outpatient prolonged services (PS) (+99354, +99355) do not match the E/M code you're adding it on to inpatient care (99221-99223). Because you used the hospital as the place of service for the E/M code, the only PS code that a payer computer system will accept is inpatient (+99356, +99357). But, you provided an inpatient service (hospital admission), not inpatient-PS. You can submit this claim three ways:
 
1. Submit it with the hospital admission code and the outpatient PS code. Include a letter of explanation.
 
2. A controversial method is to bill the outpatient E/M service (99211-99215) and the outpatient PS codes for the date the pediatrician hydrated the child in the office and sent him to the hospital. If you do not perform a complete history and physical in the hospital that day, but do so the next day, as is probably the case, bill the hospital admission for the next day. Use your history and physical for the outpatient day, and call in the order to the hospital for hydration.
 
3. Another controversial method involves billing the outpatient E/M service with modifier -25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), the outpatient PS and an admission code. There would be two separate and distinct E/M services.
 
You did your best to keep the child out of the hospital, and you should be reimbursed for your time spent hydrating the child. CPT has no system for this circumstance. Most plans require notes with PS codes. Therefore, a paper claim would be necessary regardless of which method you use.