Pediatric Coding Alert

What do insurers expect for documentation of tympanometry or other diagnostic tests? That's the question Pediatric Coding Alert subscriber Paula Escobar with Riverside Pediatric Group asked, so we went looking for answers.

Starting point: Payers' expectations depend partly on the procedure and associated CPT code, specifically whether the procedure has both professional and technical components or a technical component alone, says Catherine Gray, RHIT, CCS, CPC-I/Cardio/GI, a medical services auditor with the Henry Ford Health System in Detroit. Read on for examples on how to handle each type of case.

If the test includes the full range of services, verify the pediatrician's portion before coding the case.

Example: A chest x-ray (71020, Radiologic examination, chest; 2 views, frontal and lateral) includes both technical and professional components. If you're reporting only the technical component, report 71020 and append modifier TC (Technical component); if you're reporting only the professional component (performing the test only), append modifier 26 (Professional component) instead. If you're coding for both the test and its reading,simply report 71020 with no modifiers.

"In order for a physician to be paid for an x-ray interpretation, he must provide and document only the interpretation for the study and must provide a written report similar to that which would be prepared by a specialist in the field," Gray explains.

Partial involvement: If a test is performed and read elsewhere, your pediatrician can still submit an E/M code,such as 99213, when he reviews additional diagnostic studies. "Your interpretation and discussion is included in the work of the E/M code," explains Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "X-ray interpretation might increase the complexity of medical decision making and justify a higher level E/M code, such as 99214 instead of 99213."

Single Component Equals Case-by-Case

The codes for some other common office procedures, by contrast, encompass only a technical component. Different guidelines apply because there's no need for an "official interpretation."

Example: The code for tympanometry (92567, Tympanometry [impedance testing]) represents a technical service without a corresponding interpretive component. No interpretive component is needed because "these tests are less complex and less subjective," Tuck says. "They don't require the same level of interpretation."

"The documentation needed to support a charge for 92567 would depend on whether the paper strip or reading would be available in the event of an audit," Gray says.

"If the strip or reading can be produced, that would be sufficient. If it cannot be produced, the documentation in the physician's note would be sufficient."

Extra step: Don't stop with collecting the test strip and physician notes. Be sure the patient's chart includes a physician order for the tympanometry and the reason for testing, such as screening (V72.1x, Examination of ears and hearing) or hearing loss (V72.11, Encounter for hearing examination following failed hearing screening or V67.59, Follow-up examination; other).

Refresh the Ground Rules

CPT's Audiologic Function Tests section includes several notes for you to remember when submitting these codes. For example:

• All audiometric tests (92550-92597) require the use of calibrated electronic equipment, recording of results,and an interpretation. That means you'll only report the single code for all its associated services.

• All services include testing of both ears. If you only test one ear, append modifier 52 (Reduced services) and include notes regarding the test.