Pediatric Coding Alert

Question: A private payer representative informed my doctors that they can bill for more than one subsequent hospital visit per day. For a second visit on the same day to an already admitted child, the doctor should report the subsequent care code with modifier 25 to indicate a separate service, according to the policy.I consider 99231-99233 "per day" codes and teach my physicians to report one code per day. If a physician has to see a patient more than one time per day, he uses a higher-level code based on time/complexity (with supporting documentation) or uses the prolonged codes, as appropriate.

Could you explain how to code multiple visits on subsequent care days?

South Carolina Subscriber

Answer: Per CPT guidelines, you would use only one subsequent care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). These are "per day," global codes, which include all the day's services. The physician would choose the appropriate level of subsequent care that reflects all the E/M services he provided and documented for the full day to that patient on the date of service.

Medicare explains this concept in transmittal 1545, effective April 1, 2008. "Both initial inpatient hospital care codes and subsequent hospital care codes are 'per diem' services and may be reported only once per day by the same physician or physicians of the same specialty from the same group practice."

Although Medicare and CPT guidelines can vary, they are the same on two hospital visits on the same day. Before coding 9923X, 9923X-25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the same day, submit a letter acknowledging the insurer's policy with a copy of CPT's and Medicare's codes instructions.

You are correct in your recommendation that prolonged services may be appropriate in these cases. When the physician spends time beyond the time indicated in 99231-99233 on multiple same-day visits, consider reporting prolonged services codes (99356-99359).