Pediatric Coding Alert

When pediatricians provide preventive-medicine services (well visits) for adolescents and young adults, how can they get paid for the extended time spent on pelvic examinations? These are patients whom pediatriciansespecially those who specialize in treating adolescentsdont want to refer to an ob-gyn. They know the patient and want to keep providing her care.

The preventive-medicine services codes (CPT 99394 , for an established patient aged 12 through 17; 99395, 18 through 39 respectively) do include well-woman exams. But adults usually go to ob-gyns for these services, so the health plan is paying for both. There must be a way that pediatricians can be compensated for the extra work they spend on these visits.

Charles Schulte, MD, FAAP, the American Academy of Pediatrics (AAP) representative on the American Medical Associations (AMA) CPT Coding Committee, says that there is no way around this problem in terms of coding. The pelvic exam is a part of the routine physical, he says.

In this situation there is a significant amount of work which is not always captured in the preventive medicine services code, says Richard H. Tuck, MD, of PrimeCare Pediatrics in Zanesville, OH, and a founding member of the RBRVS RUC of the AMA. There is no code for a pelvic exam, and there is a lot of work involved in doing it in pediatrics. The only two options, says Tuck, are to realize that youll have to absorb the extra cost, or to have the patient return for a separate visit for the pelvic exam.

Having the patient come back at another time for the pelvic exam is the route chosen by the Pediatric Center, a three-pediatrician, four-nurse practitioner office in Stone Mountain, GA. We schedule a pelvic separately from the well visit, says office manager Dee-Jay Beard. We need a lot more time than what we have in the system for a well visit if theres going to be a pelvic exam and counseling, she says.

First, a female nurse practitioner sees all the teenage girls in the practice, for well visits as well as for pelvic exams, even though one of the pediatricians specializes in adolescent medicine. Its because the girls are attached to their nurse practitioner, Beard explains. Second, the nurse practitioner, if she determines that a pelvic is necessary, may not want to do it at that time for clinical reasons, as well as scheduling reasons. Also, in many instances exam the patient may not be aware there is going be a pelvic exam. The girls need time to get prepared for it, says Beard. They dont usually want to have it right then and there.

So the patient is rescheduled for a pelvic examination. At that subsequent visit, Beard uses a regular office visit codeusually 99214, she says. Theres a lot that goes into these visits, she notes. However, she doesnt use the same diagnosis code that she uses for the well visits (V20.2, routine infant or child health check). You could not use V20.2 again, as this is an office visit, not a well visit. Instead, she uses whatever diagnosis code the nurse practitioner has found to be appropriate.

Sometimes we can use contraception counseling (V25.09, advice; V25.02, fitting of diaphragm; V25.01, birth control pill prescribing, etc.), says Beard. The V25.0x series is only for advice and counseling, its not for a pelvic exam. The V25.4x (surveillance of previously prescribed contraceptive methods) series should probably be used for a patient who has had contraception previously prescribed. But, as Beard notes, some insurance companies wont cover any contraceptive diagnosis codes at all. Some carriers view contraception services as something that should be done as part of preventive-medicine services, and therefore wont pay it as the diagnosis for an office visit.

Other diagnosis codes Beard uses include menstrual problems (626.2, frequent; 626.1, infrequent; 625.3, painful; 626.8, retained). These are often the most successful in terms of getting paid. Of course, if there is no diagnosis code that accurately describes the situtation, you cannot bill the insurance carrier for the visit.

The most appropriate diagnosis code would probably be V72.3 (gynecological examination), which includes an annual pelvic exam and a Pap smear. However, its extremely difficult to get paid for an office visit with this diagnosis code, since its viewed as something which should be done during preventive-medicine services.