Pediatric Coding Alert

Question: A regional pediatrician who works in urgent care on a Saturday night sees a patient for an urgent visit. The patient has received care in the region, but not for more than three years. Should this be a new visit?

Wyoming Subscriber

Answer: The patient's status depends on whether any pediatricians in the same group practice have provided professional services to the patient within the past three years. If the patient, as you indicate in the first scenario, has not received a

face-to-face (F2F) professional service by a physician from the group and billed with a specific CPT code in the previous three years, consider the patient new (99201-99205, Office or other outpatient visit for the evaluation and management of a

new patient ).

On the other hand, if a co-pediatrician using the same group number rendered services to the patient and reported it with a CPT code, you should consider the patient an established patient (99211-99215, Office or other outpatient visit for the

evaluation and management of an established patient ).

The care does not have to be at the same location provided the physician is from the same specialty in the same group practice; it could have occurred at a pediatric office and now the patient is presenting to a co-pediatrician an urgent care

clinic. In addition, the fact that the patient has not had a preventive medicine service in the specified time period does not matter. The patient is established if he has received a billable F2F service from a physician within the same specialty who

belongs to the same group practice.

To choose the applicable after-hours/weekend special services code, ask, "Did the patient come in for care during posted business hours?"

• If the patient came in for care after your posted business hours, you can use 99050 (Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed [e.g., holidays, Saturday or

• Sunday], in addition to basic service). For instance, if a patient who has not received any services from your group in the past three years requires urgent care at 8 p.m. and your center lists hours from 8 a.m. to 5 p.m., you could use 99050 in

  addition to 9920x (new patient office visit).

  • For care provided during open weekend hours, 99051 (Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service) is appropriate for care on a Saturday. For instance, if your

  • pediatrician at your urgent care center, which has Saturday hours from 8 a.m. to 8 p.m., provides an urgent visit at 7 p.m. to a patient who received treatment last year by a co-pediatrician at your pediatric practice, you could use 99051 in addition

    to 9921x (established patient office visit).