Pediatric Coding Alert

When a child is dehydrated due to gastroenteritis, many pediatricians send the patient to the hospital for intravenous hydration. They reason that it is less and trouble to treat the problem in this manner than to treat it themselves. What they don't realize, however, is that hydration treatment in the office, when coded properly, pays well enough to make it worth the time. Furthermore, the parent and child prefer to avoid the hospital, making in-office hydration good for customer satisfaction as well as reimbursement. But, you need to know the correct codes.
 
For the first hour, use 90780 (intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour). Bill additional hours with add-on code 90781 ( each additional hour, up to eight hours [list separately in addition to code for primary procedure]). Pediatricians can usually accomplish intravenous hydration in about one to three hours.
E/M Codes in Addition?
All cases of gastroenteritis will require a separately identifiable E/M visit to assess the cause of the vomiting and dehydration, says Richard H. Tuck, MD, FAAP, at PrimeCare Pediatrics in Zanesville, Ohio. Payment, however, may depend on the plan's policies.
 
For example, a patient has straightforward, infectious gastroenteritis, probably caused by a virus. Use the E/M code (99212-99215) with modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), and 90780 for hydration. Or a patient has food poisoning; bill the E/M code with modifier -25 and 90780. Or the patient has pneumonia with secondary vomiting and fever and dehydration. Use the E/M code with modifier -25, 90780, and Rocephin (J0696).
 
"Technically, the pediatrician can bill an E/M as well, if performing a separately identifiable service," says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C. "First, you examine the child, and then you decide on the treatment."
 
But, reimbursement for the E/M is carrier-specific, Callaway says. Some payers, whenever they receive a claim that has a procedure and an E/M, always query the E/M, she says. "They expect you to prove that you did something else." Documentation is crucial: Write a good E/M note and make sure it is in a separate paragraph from the note about the hydration.
 
The need for modifier -25 is also carrier-specific, Callaway says. "Just as the carrier will decide whether to pay for the E/M in addition to the procedure, the payer will decide whether you need modifier -25 on the E/M."
No Prolonged Services Codes
Do not use prolonged services codes (99354-99355) with intravenous infusion codes, as 90780 and 90781 are by definition time-based. Some pediatricians might use prolonged services codes instead of [...]