Primary Care Coding Alert

The latest National Correct Coding Initiative (NCCI)  edits confirm a coding guideline you probably know: Insurers won't cover two same-day E/M services - even if one is for an office visit and the other is for inpatient daily critical care. Critical Care Includes More Than 75 Services NCCI version 10.0, effective Jan. 1, bundles numerous E/M codes with revised codes for pediatric critical care (99293, Initial inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child; and 99294, Subsequent inpatient pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child) and neonatal critical care (99295, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less; and 99296, Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less).
 
"When you use 99293-99296, NCCI indicates that you cannot concurrently bill many outpatient and inpatient codes," says A. Clinton MacKinney, MD, MS, the American Academy of Family Physicians representative to the AMA CPT advisory committee. Payers that follow Medicare's edits now include the following services with pediatric and neonatal critical care codes:

  office visits - 99201-99215
  observation discharge - 99217
  observation care - 99218-99220
  hospital care - 99221-99233
  admission and discharge services - 99234-99236
  hospital discharge services - 99238-99239
  consultations - 99241-99275
  emergency department services - 99281-99285
  pediatric critical care patient transport - 99289
  critical care services - 99291-99292
  nursing facility services - 99301-99316
  domiciliary, rest home, or custodial care services
   - 99321-99333
  home services - 99341-99350
  newborn care - 99431-99435.

Translation: If your FP provides any of the above services on the same day he performs pediatric or neonatal critical care, you should bill only 99293-99296. The edits contain a "0" modifier. So, you may not use a modifier, such as -59 (Distinct procedural service) to override the bundle.
 
But you may report an included same-day E/M when physicians in separate practices or specialties perform the services. For instance, after an FP admits a normal newborn to the hospital, the neonate develops sepsis (771.81, Infections specific to the perinatal period; septicemia [sepsis] of newborn). The FP turns over the infant's care to a neonatologist who admits the patient to neonatal critical care.
 
In this case, because different specialists provide the E/Ms, each physician should report his or her services, says Richard A. Molteni, MD, FAAP, a neonatologist at Children's Hospital and Regional Medical Center in Seattle. The FP would bill for the history and examination [...]