Pediatric Coding Alert

And assess health risk with this recent CPT^® code

Strange symptoms? No specific diagnosis? It's an unusual situation that could be the result of lead toxicity.

So, read on for a detailed look at a lead toxicity case, and be prepared if this scenario ever comes across your desk.

The encounter: Your provider sees a 6-year-old boy who presents with stomach problems, hyperactivity, and speech delay. While taking the child's history, the pediatrician learns that the child lives in a house that was built in the 1950s. The provider suspects the child has been exposed to lead and begins by ordering a health-risk assessment and a lead screening.

Evaluation: Your provider will begin with administering a health-risk assessment, which you can document using CPT^® code 96160 (Administration of patient-focused health risk assessment instrument [eg, health hazard appraisal] with scoring and documentation, per standardized instrument).

But be warned. "Because it is new this year, the payers are all over the place when it comes to paying for it," cautions Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana. "Paying for any screenings is carrier-dependent. Some will pay for the screenings as recommended by Bright Futures, others just will not cover screenings of any type, even Ages and Stages, MChat, or Vanderbilt."

Likewise, Mary I. Falbo, MBA, CPC CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, advises that "you may bill this service if the instrument was administered and scored in a diagnostic setting in conjunction with an office visit." But, she goes on to note, "you should not bill 96160 separately when the service is explicitly included in another service beingfurnished."

Code the test: Similarly, coders may even find a test for lead toxicity such as 83655 (Lead) to be problematic. Because the Food and Drug Administration (FDA) and the Centers for Disease Control (CDC) have given the test Clinical Laboratory Improvement Amendment (CLIA) waiver status, your practice must have CLIA-waived certification before you perform this task. Also, you'lllikelyhave to attach HCPCS modifier QW (Clia waived test). As always, checkfirst with your payer to make sure of their preferred way to code the service.

You might also be able to use CPT^® codes 36415 (Collection of venous blood by venipuncture) or 36416 (Collection of capillary blood specimen [eg, finger, heel, ear stick]) for lead testing, but like 96160 and 83655, different payers may or may not pay for the services. Falbo notes that many payers view 36416 as being inclusive to 83655. "So, if your provideris sending the lab out," Falbo advises, "you could bill CPT^® 36415/36416 for the blood draw. But if they do it in-house, you would bill CPT^® 83655-QW, checking with the payer to see if the blood draw isbundled."

Code the Encounter and the Dx: As for coding after the test, both the CDC and American Association of Pediatrics (AAP) regard a result indicating blood lead levels ≥ 5 mcg/dL as the threshold for triggering care management services for the patient. At this point, according to Holle, "Z13.89 (Encounter for screening for other disorder) is the most common diagnosis code for screenings."

You'll also use additional codes such as Z77.011 (Contact with and [suspected] exposure to lead) to document the encounter and T56.0X1 (Toxic effect of lead and its compounds, accidental [unintentional]) for the diagnoses, remembering to follow ICD-10-CM instructions to add either A (initial encounter), D (subsequent encounter), or S (sequela) as the appropriate seventh character, depending on the context of the patient's care management.

From there, your provider could document an array of symptoms depending on the level of lead detected in the patient. As lead levels can affect brain development, codes such as F80-F89 (Pervasive and specific developmental disorders) and R62 (Lack of expected normal physiological development in childhood and adults) may come into play.

Lead also affects digestion, so you may have to use one or more of the K codes from Chapter 11 of ICD-10-CM. Other, more unusual sequela could include D50 (Iron deficiency anemia ...) and even F98.3 (Pica of infancy and childhood). And you may even find yourself reaching deep into the R codes (Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified), especially as you may find that, per the ICD-10-CM guidelines, your provider determines that "no more specific diagnosis can be made even after all the facts bearing on the case have been investigated."