Pediatric Coding Alert

Test your coding knowledge. Determine how you would code this situation before looking at the box below for the answer.

Question: How should we bill when we have a child in our office for outpatient therapy? For example, we had to treat a girl for an allergic reaction. She was treated by the pediatrician and then asked to wait in the waiting room for an additional three minutes, during which time we would observe her. The office visit we would charge would be 99212, but for the additional time that she is being observed for any further reaction is there any other code that we can use? We were going to use 99354 or 99355 but we were told that there is a code to be used for office outpatient therapy. Could you please let us know?

Pennsylvania Subscriber


Answer: Assuming that when a patient comes into the office in distress due to an allergic reaction, he or she is examined and treated but must remain in the office setting to be observed as to the effectiveness of the treatment, then CPT code 99214 is probably appropriate for the level of care. But remember that this code may not be sufficient for the complexity of medical decision or the time spent with the patient or family. Code 99214 is typically 25 minutes face to face, and CPT 99215 is 40 minutes.

Remember that face-to-face time is that which is associated with the services described for an E/M code for the total work done before, during, and after the visit. If 40 minutes were spent, the provider probably devoted most of that time to giving care and talking with the patient or family. Therefore, a 99215 would be justified. It is extremely important to have proper documentation for all of the care provided during the course of the office stay. Additionally, the use of code 99354 may be charged in addition to the E/M code as long as the total duration of the prolonged service is greater than 30 minutes.

However, if the observation is just a matter of the patient sitting in the waiting room, during which time the nurse looks in on the child occasionally, or maybe only at the end of the allotted time, you cannot bill. The physician must be involved in face-to-face time during the observation for it to be billable.