Pediatric Coding Alert

Normally, when coding an examination for suspected molestation, the pediatrician should use an E/M services code 99201-99205 for a new patient or 99212-99215 for an established patient. Choose the level based on your documentation of the exam, the history and medical decision-making. For a new patient, all three components must be met to justify coding a certain level. For an established patient, you need two of three.

Note: For more information on how to choose a level of service, see Pediatric Coding Alert, January 2001, page 1.

If counseling consumes more than 50 percent of the time spent with the patient and family, you can use time as a factor in determining your level. For example, if you spend 20 minutes on the exam and 40 minutes on counseling, you can bill CPT 99215 based on time alone.

Most of these encounters would be level five with prolonged services, says Charles J. Schulte III, MD, FAAP, the American Academy of Pediatrics (AAP) representative to the AMA CPT advisory committee and a practicing physician in Washington, D.C. These lengthy sessions would be coded 99215 (on the first line of the claim form) based on time, with +99354 for the first 30 extra minutes of counseling (on the second line). You need to spend a total of at least an hour and 10 minutes with the patient.

Consultation Codes Can Be Appropriate

You can bill a consultation if the request for the exam came from an agency, says Joel Bradley, MD, FAAP, editor of Coding for Pediatrics, a member of the AAP coding and reimbursement committee and a practicing pediatrician in Clarksville, Tenn. The patient need not be referred by another physician to bill a consultation. Human Services fits the requirement of other appropriate source in CPTs definition of consultation.

If you are asked to see the child by Child Protective Services, for example, report the appropriate consultation code with modifier -32 (mandated services) appended, Some private insurers may not pay initially when modifier -32 is appended; check with the payer first to see if you need to file a paper claim.

Dont ignore the high relative value units (RVUs) of consultation codes, says Bradley. The highest office visit code 99215 has an RVU of 3.06. If, however, the pediatrician does the same work (comprehensive history and examination with high-complexity medical decision-making) and the visit is a consultation (99245), the RVU is 5.73. The consultation will usually pay about twice as much, he notes. Even a new patient code 99205 with an RVU of 4.38 would fall short of the highest-level consultation code.

When determining the level based on time, however, remember that consultation codes require more of it. The total visit time for the highest-level consultation code is 80 minutes, but you only need 60 minutes to qualify for 99205 or 40 minutes for 99215.

New Colposcopy Code Eases Billing

Pediatricians can now access a code specifically for a colposcopy done as part of an exam for suspected child abuse (the code is also for use in other, non-abuse situations, such as if a child inserts a foreign object into his or her body). The code 99170 (anogenital examination with colposcopic magnification in childhood for suspected trauma) was created to help pediatricians bill for a procedure for which reimbursement was formerly difficult.

When performing 99170, the pediatrician will probably undertake a general physical examination as well. Bill the office visit with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and the colposcopy, Schulte recommends. He notes that 99170 is only to be coded when you use a colposcope.

Note: With colposcopy, you may also provide conscious sedation. If you do so, add 99141 or 99142 to the claim.

If your office doesnt perform colposcopies and one needs to be done in a case of suspected rape you will probably refer the case to a crisis center, pediatric gynecologist or emergency room in a childrens hospital, where personnel are skilled in such procedures. But when the abuse allegations are more vague, the general office-based pediatrician as the trusted provider for the family might prefer to conduct the exam. Cases typically seen by the general pediatrician include a child in day care whose parents suspect abuse or the child of estranged parents who comes back depressed from every weekend at the fathers or mothers house.

Use Injuries Found as Primary Diagnosis

For the diagnosis code, Use whatever sign or symptom brought the child to you or is found by you, recommends Charles A. Scott, MD, FAAP, regional coding trainer for the AAP and an office-based pediatrician in Medford, N.J. You may find a laceration of the vagina, a bruise or vaginitis. Code the symptom.

If there are no injuries, you can code V71.5 (observation and evaluation for suspected conditions not found; observation following alleged rape or seduction). However, you many not wish to put this in a childs record. Another possible diagnosis is V71.81 (observation and evaluation for suspected conditions not found; observation for other specified suspected conditions; abuse and neglect).

If you plan to use the V codes, you should explain the situation to parents first, says Tom Kent, CMM, CPC, president of Kent Medical Management, a compliance and coding consultancy based in Dunkirk, Md. The parents might prefer to pay for the office visit rather than have the insurance claim submitted and placed in the childs permanent record, he says. Of course, regardless of the diagnosis code you use and who pays for the encounter, you must report possible abuse to the authorities.

Note: When accepting cash from parents, take extra care to be sure the claim is not inadvertently submitted.