Pediatric Coding Alert

CCI also impacts how you’ll report newborn services with critical care.

With the New Year comes new CPT codes -- and unfortunately, new Correct Coding Initiative (CCI) edits. CCI 19.0, which took effect on January 1, 2013, adds 37,587 new bundles and deletes 16,716. Although these edits don’t normally cause massive issues for pediatricians, this round is different—you’ll find more than one new bundle that will create denials at your practice, if they haven’t already.

One practice contacted Pediatric Coding Alert saying that she’d faced over 200 denials in one day alone thanks to this new round of edits. Read on for clarification of the edits, and tips on how to stave off denials.

Vaccination Edits Will Trip Up Your Coding

Chief among most pediatric offices’ complaints is the new edit that bundles well child visit codes 99381-99385 and 99391-99395 into the vaccine administration codes (90460-90461 and 90471-90474). As most coders may recall, no CCI edit previously barred you from reporting immunization administration with preventive medicine visits. This year, however, these two services are bundled with a modifier indicator of “1,” and the well child visit is listed as the “column two code,” which means that it is the bundled code. Therefore, if you don’t add a modifier to your claim, you will collect for the vaccine administration but you’ll face denials for the well child visit code.

Solution: Currently, you must append a modifier such as 25 (Significant, separately identifiable evaluation and management (E/M) service by the same physician on the day of a procedure) to the well child code when you report it with the vaccine administration code. You won’t need to append a modifier to the vaccine code since it is the “column one” or “primary” code.

What this means:  Even though the vaccine administration code and the well child visit are bundled, you can override the edit by using modifier 25 on the well-child code.

AAP response: On its Web site, the American Academy of Pediatrics likewise recommends the use of modifier 25 on this bundle, “but only when the E/M service is significant and separately identifiable,” the AAP says. Hopefully a future edition of CCI will correct this edit, since the AAP notes that “the Academy is urgently working with National Correct Coding Solutions - the CMS contractor for NCCI edits - to have the edits suspended.”

Sick Visit Codes Also Impacted: Although pediatricians are more likely to administer vaccines at a well child visit, you probably also give them at sick visits (99201-99215) from time to time. Unfortunately, the new CCI bundle does extend to sick visits as well, and these codes now bundle into the vaccine codes, which means you’ll be busy appending modifier 25 to your sick visit codes as well when you provide those services with immunization administrations.

Double modifier use: If you perform a medically necessary additional E/M service provided with a well child visit and immunizations, you will append modifier 25 to both the well child visit and the sick visit code.

Additional Bundles Target Hospital Care

In the past, if you performed a normal newborn service (99460) along with intensive care or critical care (such as 99468), you were able to bill the newborn care service with no modifier, but the intensive or critical care code would have a modifier 25 appended. However, the new batch of edits reverses that, forcing you to append the 25 modifier to the newborn service and not the critical care code.

For instance: The physician sees a patient for normal newborn care, but later that day he performs critical care on that same patient after she develops severe respiratory distress. Effective for services performed on or after Jan. 1, you’ll report 99468 followed by 99460-25.

Contradiction: This new CCI contradicts the language currently in CPT 2013, which states, “When a newborn becomes critically ill on the same day they have already received normal newborn care (99460, 99461, 99462), and the same individual or group assumes critical care, report initial critical care service (99468) with modifier 25 in addition to the normal newborn code” (emphasis added by Pediatric Coding Alert).

AAP response: The AAP has already contacted the CCI contractor requesting that they flip the edit so that the CCI rules jell with CPT’s instruction.

Stay tuned to Pediatric Coding Alert for more updates on these CCI bundling issues, which will hopefully be resolved by the next edition of CCI in April, if not before then.