Pediatric Coding Alert

How well do you know the well-visit rules?

Once you’ve reviewed the scenarios on page 3, compare your answers with the ones provided below:

Scenario 1 Answer:

For the preventive exam: You’ll use 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)) with Z00.110 (Health examination for newborn under 8 days old).

Why? As the child has already received professional, face-to-face services from your pediatrician within the past three years, and those services have presumably been services reported by a specific CPT^® code, the child is regarded as established to your practice even though this is the child’s first encounter in your office. This means you will choose 99391 instead of 99381 (Initial comprehensive preventive medicine evaluation and management of an individual … new patient; infant (age younger than 1 year)).

Remember this new patient advice: “It is a common misconception that place of service [POS] has a bearing on whether a patient is considered new to a practice. It does not. Unless your clinicians are acting in the capacity of different subspecialties when treating the patient, the very first service rendered effectively establishes the patient with your practice,” says Jan Blanchard, CPC, CPEDC, CPMA, Pediatric Solutions Consultant at Vermont-based PCC. But remember, “payer rules may come into play when defining ‘subspecialty’ in this context,” Blanchard adds.

Additionally, as this is an exam for a newborn under 8 days old, you will use Z00.110 rather than Z00.121 (Encounter for routine child health examination with abnormal findings). That’s because the newborn exam code takes precedent over the abnormal findings code, as the Excludes1 instruction for Z00.11- under Z00.121 indicates.

For the abnormal findings: You’ll use P83.81 for the umbilical granuloma. Then, “the tricky thing is you should code for both the newborn visit and the procedure itself. But because all procedures have a little bit of E/M [evaluation and management] built into them, you should not bill out an E/M associated with the granuloma,” recommends Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts. This would mean using 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) for the cauterization.

What about an E/M? In the absence of a CPT^® code to describe a procedure documenting the additional and significant work required to treat an abnormal finding uncovered during a well visit, you may justify billing for an office/outpatient E/M in addition to the preventive E/M. If this happens, remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the office/outpatient E/M “to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service” per CPT^® guidelines.

Scenario 2 Answer:

For the preventive exam: You’ll also use 99391, but this time you will use Z00.121 for the exam with abnormal finding.

For the abnormal findings: Per the instructions for that code, you will also use an additional code for the abnormal finding — in this case, L22 (Diaper dermatitis). But as the finding did not lead to a separate and significant office/outpatient E/M or a procedure, that will be the extent of the coding for this preventive E/M in this situation.

For the vaccinations: Per CPT^® guidelines for the preventive medicine E/M service codes, “vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg, vision, hearing, developmental) identified with a specific CPT^® code are reported separately.”

This means you can code for the vaccines, most likely with the following:

• 90698 (Diphtheria, tetanus toxoids, acellular pertussis vaccine, Haemophilus influenzae type b, and inactivated poliovirus vaccine, (DTaP-IPV/Hib), for intramuscular use)
• 90670 (Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use)
• 90680 (Rotavirus vaccine, pentavalent (RV5), 3 dose schedule, live, for oral use)
• 90744 (Hepatitis B vaccine (HepB), pediatric/adolescent dosage, 3 dose schedule, for intramuscular use)

The trick here, though, is to use the correct administration codes and units. As the pediatrician counseled the parent, you’ll use 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered). And, because there were four administrations, you will report four units of 90460.

For 90698, however, you will also be able to bill an additional four units of the add-on administration code +90461 (… each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)).

Why? “Since there are five components identified in 90698, you would code one initial 90460 and four units of +90461 for each additional component,” Walaszek advises.

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