Pediatric Coding Alert

If you're not clear on the associated services you can code outside a preventive medicine service, you could overlook charging many ancillary services.

"The American Academy of Pediatrics recently issued new age-appropriate preventive medicine guidelines," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. The Bright Futures Guidelines recommend evidence-based periodicity for history, measurements, sensory screenings, developmental/behavioral screenings and procedures. Here's what you can capture in addition to the preventive medicine service code (99381-99385, New patient preventive medicine service; 99391-99395, Established patient preventive medicine service).

You take history and measurements at all preventive medicine services, except neonatal, "which are give-aways, pure and simple," says Herschel R. Lessin, MD, vice president and clinical research director at The Children's Medical Group in Poughkeepsie, N.Y. "The history and measurements are part of the preventive medicine code and cannot be billed separately."

Exception: Your history uncovers a specific problem, Lessin says. In this case, you would need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bill a separately identified and documented E/M service (99201-99215, Office or other outpatient visit ...).

Heads up: The added body mass index (BMI) recommendation starting at age 2 means you may report an additional ICD-9 code. Use the BMI percentile to choose the correct V85.5x code. For instance, you would represent a 3-year-old girl's 10 percent BMI with V85.52 (Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age).

Similarly, you would include the examination in the preventive medicine service.

CPT does not include ancillary services and screenings in the preventive medicine service codes. Therefore, you should separately report any vision or hearing screening.

Example: At a 6-year-old's established patient preventive medicine service, a nurse tests the child's vision with a Snellen wall chart and his hearing with a pure tone audiometer. The child passes both screens. You should report 99393 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ... late childhood [age 5 through 11 years]), 99173 (Screening test of visual acuity, quantitative, bilateral) and 92551 (Screening test, pure tone, air only) with V20.2 (Routine infant or child health check).

You should not, however, separately code the risk assessment, such as using informal questions to assess for vision or hearing problems, that the guidelines recommend providing at preventive medicine services, in which screenings aren't indicated. If your risk assessment resulted in a positive, meaning the child required screening, you would then code the appropriate sensory screening code.

The guidelines break developmental assessment into two portions:

1. Surveillance, which "is a flexible, ongoing process where knowledgeable professionals perform skilled observations of children during the healthcare visit," according to the Tennessee AAP's EPSDT Manual. When you provide and document surveillance often through an age-appropriate checklist, include the work as part of the preventive medicine service.

2. Screening may arise from an age recommendation or from positive surveillance. If you use a standardized, validated tool, such as the Parent Evaluation of Developmental Status (PEDs) or Ages and Stages Questionnaire (ASQ), you should separately report the screening with 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) and V20.2 if the test is normal. You may also use ICD-9 codes, such as 315.31 (Expressive language disorder), for any findings related to a positive screening.

For autism screening, which the Bright Futures guidelines recommend at the 18- and 24-month visits (99382, ... early childhood [age 1 through 4 years] or 99392), you'll use the same developmental testing code 96110. Once again, to use the code, testing must involve a standardized, validated tool, such as the Australian Scale for Asperger's Syndrome or the Modified Checklist for Autism in Toddlers (M-CHAT).

The Pediatric Symptom Checklist (PSC) and PSC-17, an emotional/behavioral screen, also qualifies as 96110.

You won't use new-for-2008 codes 99408-99409 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services ...) to represent the alcohol and drug use assessments now recommended at ages 11-21. These codes require an intervention in addition to a screening. You'll instead include a negative risk assessment in the preventive medicine service.

Of course, you should separately code for the bread and butter of your services, immunizations. Make sure to report both the product (90476-90749) and its administration (90465-90474), unless you are billing Vaccines for Children (VFC). Because this program distributes the product for free, you are to charge only for the administration using the product code.

For private payers, identify each product's administration by linking the product's V code to the administration code as well. Some payers prefer and/or accept V20.2 for all administration codes.

CPT has separate codes for vaccine administration with counseling. If the pediatrician provides vaccine counseling and the child is less than 8 years old, use 90465-90466 (intramuscular) or 90467-90468 (intranasal) with V03.81-V06.8. For children age 8 and older and/or for administration without physician counseling, report 90471-90472 (IM) or 90473-90474 (IN) linked to V03.81-V06.8.

If you have a certificate of Clinical Laboratory Improvement Amendments (CLIA) waived status, you may conduct some preventive medicine service-related tests in your office.

These include hemoglobin testing (85018, Blood count; hemoglobin [Hgb]), which is recommended at the 12-month preventive medicine service (99382, 99392), dipstick urinalysis (81002, Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy), which the guidelines no longer require at any age, and a lipid panel (80061) for dyslipidemia (cardiovascular) screening, preferred at the 20-year visit (99385, ... 18-39 years; or 99395 linked to V70.0, General medical examination; routine general medical examination at a healthcare facility).

You may separately report performing these tests. Some insurers may want HCPCS modifier QW (CLIA waived test) appended to the test code.

Exception: The tuberculin skin test does not require CLIA status. You may simply code this with 86580 (Skin test; tuberculosis, intradermal) and V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis).

You might order several other lab tests, such as PKU for the newborn metabolic/hemoglobin screening and screenings for lead, sexually transmitted infection (STI) and cervical dysplasia. But because a lab analyzes these tests, you will probably not report the test's CPT laboratory code.

Exception: If you have a lab agreement, in which your office bills for tests that the lab performs, you would use the CPT code appended with modifier 90 (Reference [outside] laboratory).

Look Out for Blood Collection

Even if the lab bills the analysis, you can still code any related collection that staff perform to conduct the test, such as a finger/heel stick (36416, Collection of capillary blood specimen [e.g., finger, heel, ear stick]) or routine venipuncture (36415, Collection of venous blood by venipuncture) linked to the screening diagnosis.

You code it: "As part of the newborn checkup, we perform the Newborn Heel Stick Screening Panel, which includes the PKU and cystic fibrosis (CF) testing, and thyroid stimulating hormone (TSH)," writes Amy Robinson, at North Oaks Pediatric Clinic in Hammond, La. "We use 83788 for the PKU screening panel and 84443 for the TSH. Is this correct, or are there more appropriate codes for these tests?"

Unless you have a lab agreement, under which your office bills for the lab-performed tests, you should code only the collection with 36416. You may link this to V77.0 (Special screening for endocrine, nutritional, metabolic, and immunity disorders; thyroid disorders), V77.3 (... phenylketonuria [PKU]) and V77.6 (... cystic fibrosis).

If you have a lab agreement, use 84030-90 for PKU.

If you perform a pelvic exam, such as for a sexually active teenager, include the service in the preventive medicine service (e.g., 99394, Periodic comprehensive preventive medicine ... adolescent [age 12 through 17 years]). You can bill for a Pap smear collection as part of a general gynecological exam with 99000 (Handling and/or conveyance of specimen for transfer from the physician's office to a laboratory) linked to V72.31 (Routine gynecological examination).