Pediatric Coding Alert

Check out the official word on these preventive coding scenarios

Just about every pediatric practice in the country reports well child visits daily, but even though these services are very common, you still might be surprised to learn some of the preventive visit coding nuances. Read on for official guidance on how to bill these services.

1. There Really Are Official Rules on Same-Day Sick, Well Visits

If a child presents for a physical and the pediatrician finds a problem that prompts a separate sick child evaluation, you may waffle on whether to report both the sick and well E/M codes—but the AMA actually addresses this situation specifically, and advises you to bill both codes.

In black and white: “If the problem is significant enough to require additional work for the physician to perform the key components of a problem-oriented E/M service, the appropriate office/outpatient code (99201-99215) should be reported, in addition to the appropriate code for the preventive medicine E/M service, and modifier 25 should be added to the office/outpatient code,” the AMA says in the July 2009 issue of CPT® Assistant. 

In addition to appending modifier 25 to the sick visit code, you should ensure that your documentation provides proof that the pediatrician performed both services and they were significant and separately identifiable. “In order for the two E/M services to be reported on the same day, the problem or abnormality encountered must require additional work effort by the physician, and the performance of the key components of a problem-oriented service outside of the health supervision work inherent in the preventive medicine E/M service,” the CPT® Assistant article says. Remember also that when doing a sick visit at the same time as a physical, the physician will typically need to base the code on history and medical decision making (MDM) as there is no medical necessity to redo the physical.

If, however, the pediatrician finds something insignificant—such as a benign-looking mole that requires no additional evaluation or refilling a medication for a chronic but stable illness—that would most likely be included in the preventive visit code and you couldn’t separately report a sick visit for it.

2. The Wrong Diagnosis Code Could Trigger Patient Fees

When you apply diagnosis codes to your E/M services, you probably know that using the wrong ones could create reimbursement problem for your pediatric practice—but did you know that incorrect diagnoses can also create financial headaches for patients?

Here’s why: Under the Patient Protection and Affordable Care Act  (PPACA) that became law in 2010, you must provide preventive care visits (such as 99381-99397) consistent with Bright Futures Guidelines for children at no cost to the patient or family, including well child exams, vision and hearing screening, immunizations, and obesity counseling, among other services.

These visits are not subject to a copay, coinsurance or deductible (as long as the insurance plan was not one that was grandfathered in), so patients who schedule them come to your practice expecting to leave without paying any money out of their pockets. However, if you link a “sick” diagnosis code to your well child visits, you could trigger a copay, coinsurance and deductible fees for your patients’ families.

In black and white: “Preventive care services must be submitted with an ICD-9 code that describes encounters with health services that are not for the treatment of illness or injury,” CIGNA says in its Guide to CIGNA’s Preventive Health Coverage for Health Care Professionals. “These diagnosis codes must be identified as the primary diagnosis code on the claim form. If claims for preventive care services are submitted with diagnosis codes that represent treatment of an illness or injury as the primary (first) diagnosis on the claim, the service will not be identified as preventive care and your patients’ claims will be paid using their normal medical benefits rather than enhanced preventive care coverage.”

3. Yes, Vaccines Say ‘With Counseling’—but E/M Codes Are Still Allowed

Ever since CPT® added the words “with counseling” to the vaccine administrative codes in 2009, pediatric practices have been confused about whether the vaccination services now include the counseling and therefore preclude you from billing a separate E/M. Fortunately, however, you can still report both the immunization and the E/M service if your documentation supports both.

In black and white: “If a significant separately identifiable evaluation and management services is performed, the appropriate E/M service code should be reported in addition to the vaccine and toxoid administration codes,” CPT® says in the introductory paragraph before codes 90460-90474. 

Example: A pediatrician performs a complete well visit on a 16-month-old patient, and counsels the mother on vaccine risks and benefits prior to giving the patient a DTaP-vaccination. The diphtheria, tetanus and pertussis each count as one component. For the vaccine administration with counseling on the components included in the DTaP, report one unit of 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered ) and two units of +90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered ). You’ll also report the appropriate preventive medicine code, such as 99391. You’ll link V20.2, Routine infant or child health check to all of the codes billed, because vaccinations link well to V20.2 and you do not need to link the vaccines to a separate ICD-9 code. Therefore, your claim will look like this:

• 90460 linked to V20.2

• 90461 x 2 linked to V20.2

• 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for intramuscular use) linked to V20.2

• 99391-25 linked to V20.2

Tip: Although not required by CPT®, more and more payers are requiring you to append modifier 25 to the preventive medicine code.