ment of liver enlargement in the context of chemotherapy for acute lymphoblastic leukemia, and 20 minutes of counseling the family, took place on the same day that the pediatric oncologist did a spinal tap on a child (delivering chemotherapy). The hospital visit code was denied as “global to the 96450” (the spinal tap code). Thus, a complex hospital visit, with the total time for the day at 60 minutes, including a procedure as well as extensive counseling, was reimbursed at $161.00. Compare this to local reimbursement rates for upper gastrointestinal endoscopy ($325.00), sigmoidoscopy ($118.30), mammogram ($94.30), and tonsillectomy/adenoidectomy ($390.00).

Even when these codes are reimbursed, the rate is not sufficient to support a clinical practice that includes a multidisciplinary team, despite its value to patients and families:

  • A clinic visit (99215) with extra counseling time, totaling 80 minutes, was reimbursed at $64.62 with the prolonged services code denied.

  • A hospital visit with management of a complex medical problem was reimbursed at $78.96 (recall that this allows up to 35 minutes before a prolonged services code is allowed to be charged). The prolonged services code 99356 was reimbursed at $96.32, adding up to $143.58 for 90 minutes of time. Physicians will be hard pressed to run a clinical service at that rate, let alone utilize the multidisciplinary psychosocial team needed by these families.

Hospital Discharge Services

The care of children with advanced illness requires a multidisciplinary team approach, but reimbursement for the contribution of nonphysician providers is extremely poor. Teams depend on staff such as nurse practitioners to do a great deal of teaching at the time of discharge. This teaching can prevent readmissions and increases the parents’ sense of control and efficacy. Payers routinely deny nurse practitioner charges for discharge services, despite their being licensed and credentialed to provide this service.

Case Management Services

Case management services (listed in CPT 2000) consist of team conferences and telephone calls, which play a huge role in the management of children with advanced illness. They are reimbursed inadequately or not at all.

TEAM CONFERENCES Billing codes exist for medical conferences by a physi-



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