Pediatric Coding Alert

In the January 1998 issue, we covered the question of whether you can code a physical as an office visit. The answer is no. The article focused on the problem that arises when a patients insurance plan doesnt cover well visits, and a pediatric office might feel tempted to code it as an office visit. Again, the clear answer is: dont do it.

However, part of the article discussed the use of a preventive medicine code and an office visit code at the same time. Victoria S. Jackson, administrator and CEO for Southern Orange County Pediatric Associates in Lake Forest, CA, stated in the article that you cant use both codes at once. Theyll downcode you to the lowest code anyway, she said.

In fact, CPT coding does allow for both codes to be used, providing that a significant problem is discovered during a preventive visit. You would do this using the modifier 25.
 

Jackson also said in Januarys issue youre not going to get paid for finding an earache during a well visit. But that doesnt mean you cant use both codes. It all depends on how significant the problem is that you discover during the well visit.

If you spend additional time over and above the time usually spent in the preventive care part of the exam because of a problem, then you most definitely can code both services, says Charles A. Scott, MD, FAAP, who practices in Medford, NJ. As an example, Scott, a regional coding resource for the AAP, cites the hypothetical case of a three-year-old who comes in for a check-up. During the visit you see that the child is having a moderate amount of wheezing requiring a nebulizer treatment as well as listening to the childs chest after the treatment before sending him home, Scott explains. The doctor should code for the well child part of the exam, but should also code for a sick visit. Scott recommends coding lower for the office visit -- using a 99212 instead of a 99213 or 99214, which you would use if the child came in for the sick visit only. Both services can properly be coded simultaneously, notes Scott, adding that you should remember to code for the nebulizer treatment as well in this scenario.

People need to be advised that insurance companies downcode, says Jackson, who stands by her quotes. One problem is the definition of significant -- it doesnt exist. Theres so much gray, Jackson tells us. You have a three-year-old who has been scheduled for his or her annual physical. You block out 15 minutes for the physical. You dont spend any extra time on it, even though you identify a problem. You better not use both codes. To use both codes, you would need to do a whole lot of additional work, Jackson says. For example, an ADHD workup that needs to be done as part of a well visit would probably qualify for both codes.

Jane Priest, coding and compliance coordinator for Kalamazoo-based Michigan Health Partners, wrote us to object to Jacksons comments in the January issue. I agree with the article from the point that if a patient presents for a well-child visit and the chart indicates that a well-child visit is performed, that a preventive medicine CPT code should be reported, she wrote. A pediatrician should not change the preventive-medicine code to a problem-oriented code because they encountered an earache or sore throat. But Priest goes on to write that both the preventive-medicine visit and the office visit should be billed when an abnormality or preexisting problem is encountered that requires additional workup or treatment.

We called Priest to ask what her rule-of-thumb is for using both codes in her practice, where there are 88 physicians, 18 of whom are pediatricians. We use both codes if dealing with both the well visit and the problem puts our pediatricians behind their schedules, says Priest matter-of-factly. And she agrees with Scott on the level of E/M service to use. You wouldnt bill at level four or five with a well visit, she says. Youve already got the comprehensive history and exam, so you are just using the medical decision-making.

But Priest isnt really in disagreement with Jackson. Heres why: even though shes using both codes, shes only getting paid for one. No one ever gets reimbursed for both. So I understand where Jackson is coming from, Priest tells us.

Scott concurs, when insurance companies dont honor these correctly-coded exams, pediatricians are left in a bind. It is enticing for the pediatrician to begin creative coding to obtain monies that are rightfully owed, he states.