Pediatric Coding Alert

Beginning Jan. 1, 2003, pediatricians can report nebulizer treatments and training sessions with confidence thanks to changes in CPT 2003's pulmonary section. In addition to understanding the revised inhaler codes, pediatric practices should pay attention to changes in the neck repair, venous, hematology and miscellaneous services subsections, which affect procedures they perform.

Revised Nebulizer Codes Expand Coverage

Pediatric practices have long sought advice regarding how to properly use nebulizer code 94640 (Nonpressurized inhalation treatment for acute airway obstruction) and training codes 94664 (Aerosol or vapor inhalations for sputum mobilization, bronchodilation, or sputum induction for diagnostic purposes; initial demonstration and/or evaluation) and 94665 ( subsequent).

CPT Codes 2003 alleviates much of this confusion by revising 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device]) and 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device) and deleting 94665.

Code 94640 now includes pressurized, as well as nonpressurized, treatments for acute airway obstruction. CPT does not restrict these treatments to services for acute airway obstruction, but incorporates sputum induction for diagnostic purposes. The code descriptor includes different treatment methods, such as aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device. You may report these when a nonphysician practitioner, such as a nurse practitioner, provides these services, says Richard Tuck, MD, FAAP, medical director of quality care partners for PrimeCare of Southeastern Ohio in Zanesville, and a member of the American Academy of Pediatrics (AAP) national committee on coding and nomenclature (COCN).

Pediatricians should note that 94640 now includes IPPB treatment, which was previously reported 94650-94652. CPT 2003 deletes these codes and includes them in 94640, according to CPT Changes 2003: An Insider's View.

CPT Clarifies Multiple Treatments/Trainings

CPT 2003 adds a note to 94640 that instructs physicians to append modifier -76 (Repeat procedure by same physician) if they perform more than one treatment on the same date. Although CPT Assistant, April 2000, already stated this, CPT now offers this advice in the manual, alleviating any confusion.

Pediatricians can also stop wondering when they should report an initial (94664 for 2002) rather than a subsequent training session (94665 for 2002). CPT 2003 deletes the term "initial" from 94664. The code now refers to any inhaler or nebulizer demonstration. Consequently, CPT 2003 deletes 94665 to remove the distinctions between an initial and subsequent demonstration. You should report only one training session (94664) per day, CPT explains in a note following the code.

When office staff under supervision demonstrates how to use an inhaler, charge 94664, says Victoria S. Jackson, CEO of Southern Orange County Pediatric Associates and owner of Omni Management, which provides practice management services for 15 medical offices in the Los Angeles area. "Use the training code rather than nurse code 99211," she recommends.

About 60 percent of pediatric offices use 94664, so the revision does not impact the field significantly, says Chip Hart, marketer for The Physician's Computer Company, which supports and develops pediatric-specific software to manage clinical and clerical duties for pediatric offices. The average three-doctor practice performs about 100 trainings each year. "The revised code will impact those rare practices that do a lot of them," Hart says.

"I don't know any pediatricians who use 94665 (that's looking at about 6.5 million procedures for 2002)," Hart says. "So, dropping it isn't a big deal."

CPT Introduces Two Pectus Excavatum Codes

Although pediatric surgeons should be aware of two new procedure codes for pectus excavatum repair, these codes may be inappropriate for general pediatricians. The two codes describe a new minimally invasive technique for funnel chest repair, which involves placing a stiff bar often using thoracoscopy as a visual tool, according to John P. Crow, MD, APSA (American Pediatric Surgical Association), Pediatric and Neonatal Coding 2003 presenter at the AMA CPT Symposium in Chicago on Nov. 14. For the Nuss procedure without thoracoscopy, use 21742 (Reconstructive repair of pectus excavatum or carinatum; minimally invasive approach [Nuss procedure], without thoracoscopy). For a minimally invasive procedure with thoracoscopy, assign 21743 ( minimally invasive approach [Nuss procedure], with thoracoscopy).

Venous: Prick Your Code Carefully

Pediatricians should note two changes to the venous codes for 2003:

Revised code 36415 and new code 36416 separate the combined 2002 definition for 36415* (Routine venipuncture or finger/heel/ear stick for collection of specimen[s]). Each procedure, venipuncture and finger/heel/ear stick, now has an individual code, which emphasizes the type of blood specimen venous or capillary. These alterations will help you appropriately assign the blood collection codes, according to CPT Changes 2003. CPT 2003 deletes the corresponding HCPCS level-two G code, G0001 (Routine venipuncture for collection of specimen[s]), that Medicare required for venipuncture and heel sticks.

About 50 percent of pediatric practices report 36415. Until the national Medicare Physician Fee Schedule releases the 2003 relative work values for 36415 and 36416, the full impact of these codes remains unknown. Pediatricians perform a lot of the new 36416, Hart says. "It might be interesting for them if they can collect for it."

Hematology Contains Many Changes, Little Impact

CPT 2003 makes several changes to the "Hematology and Coagulation" subsection. Pediatricians should check whether blood count regulations and laboratory procedure certifications mandated by the Clinical Laboratory Improvement Amendments (CLIA) allow them to perform these tests. Pediatricians should refer to CPT 2003 to verify the correct codes for any tests they perform in the office.

Changes include introducing 85004 (Blood count; automated differential WBC count) for an automated white blood cell count. To incorporate this addition, CPT updates 85007-85009. Code 85004 replaces 85007 (Blood count; manual differential WBC count [includes RBC morphology and platelet estimation]) as the new base code for 85004-85049). These changes, however, do not affect spun hematocrit code 85013 ( spun microhematocrit) because the code maintains the same base phrase "blood count."

Pediatricians may also continue to use hemoglobin code 85018 ( hemoglobin [Hgb]). An editorial change "was made to add the abbreviation for hemoglobin (Hgb) to the description," CPT Changes 2003 notes.

CPT 2003 deletes 85024 ( hemogram and platelet count, automated, and automated partial differential WBC count [CBC]). You should report new code 85025 ( complete [CBC], automated [Hgb, Hct, RBC, WBC and platelet count] and automated differential WBC count) instead.

Try New Code for On-Call Service

Pediatricians who have privileges at hospitals that require on-call services will be able to code for their services in 2003. Physicians who previously could not code for the time hospitals required them to reserve for on-call duty will welcome 99026 (Hospital mandated on call service; in-hospital, each hour) and 99027 ( out-of-hospital, each hour). "At this time, we are unsure whether private payers will reimburse for these codes, but you will never know until you try," says Barbara Cobuzzi, MBA, CPC, CPC-H, a coding and reimbursement specialist and president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J.

Physicians should ask their carriers to make a written determination regarding whether they will accept these new codes, Jackson says. That way, if the payer accepts 99026-99027, the doctor can bill the codes. If the insurer refuses to cover on-call services and no contractural restrictions exist, the physician can bill the patient. If the on-call services are generalized rather than patient-specific, balance-billing the patient may prove difficult.

For physician standby services requiring prolonged physician attendance, you should use 99360 (Physician standby service, requiring prolonged physician attendance, each 30 minutes [e.g., operative standby, standby for frozen section, for cesarean/high-risk delivery, for monitoring EEG), as appropriate, CPT says. In addition, do not include time the pediatrician spends performing separately coded procedure(s) or service(s) in time reported as mandatory on-time call.