Pediatric Coding Alert

If your payer follows CCI, remember face-to-face outweighs other options.

If any of your payers follow Medicare's Correct Coding Initiative (CCI) edits, watch your providers' coding for phone consults. Recent CCI edits include more than 100 code pairs that center on telehealth services, so be sure providers know when they can -- or can't -- separately report these consultations.

Steer Clear of Telehealth Reporting

The G codes in HCPCS apply to Medicare carriers, but might have some application for pediatricians whose payers follow Medicare guidelines. CCI 16.2 clarifies that CPT and CMS coding instructions prohibit you from reporting two sets of telehealth consultation codes with many E/M services:

• G0406-G0408 -- Follow-up inpatient, telehealth consultation ...
• G0425-G0427 -- Initial inpatient telehealth consultation ...

The consultation level (limited, intermediate, or complex) and amount of physician time spent during the consultation distinguish the codes in both groups.

Correct approach: Instead of reporting the telehealth code, opt for the appropriate face-to-face E/M service the pediatrician provides. Affected codes include 99468-99476 (codes for initial and subsequent inpatient critical care of neonates or pediatric patients) and 99477-99480 (codes for initial and continuing intensive care services of neonates and pediatric patients).

Edits Also Hit Initial, Subsequent Care

The codes you report for seeing patients under "normal" circumstances -- face-to-face in an inpatient setting -- also override the telehealth consultation choices. For example, submit the appropriate choice from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) or 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...) instead of the G code.

No breaks: Each edit pair carries a modifier indicator of "0," so you cannot report modifier 59 (Distinct procedural service) to bypass the bundle and report both services during the same encounter.

Timing: CCI 16.2 went into effect July 1, 2010, and encompasses 16,843 new edit pairs, according to analyst Frank Cohen, MPA, of MIT Solutions, Inc., in Clearwater, Fla. For a full list of current CCI edits, visit www.cms.gov.