Pediatric Coding Alert

Pediatricians are the latest group charged with trying to prevent childhood obesity's spread. Our experts reveal the CPT codes you should use for this work directive.

Before you code for the American Medical Association's (AMA) newly recommended dietary childhood assessments, get up-to-speed on the mandate's details. All children should "receive at least an annual assessment of their weight, dietary habits and physical activity levels," according to the article, "Expert Panel Gives Very Heavy Children a New Label -- Obese," in the July 9, 2007, issue of American Medical News published by the AMA. The assessment should address problematic issues, such as frequent restaurant dining, drinking large amounts of sweetened beverages and excessive screen viewing time.

The article calls for additional labs in problem patients. If the pediatrician diagnoses the child as overweight, staff should measure the patient's blood pressure and pulse and order lipid studies. The physician should also test obese children's liver and kidney functions.

Should you classify these assessments as preventive medicine counseling, preventive medicine services or sick visits? Experts walk you through the coding do's and don't of these latest recommendations.

Question: Should you account for this weight-related work by using 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) in addition to the well checkup code?

Answer: No. This code combination is incorrect for one simple reason. "CPT categorically does not allow you to report counseling and/or risk factor reduction intervention codes at the same encounter as a preventive medicine service," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare in Zanesville, Ohio. Pediatricians must provide 99401-99404 "at a separate encounter for the purpose of promoting health and preventing illness or injury," stipulates the AMA in CPT's counseling and/or risk factor reduction intervention introductory notes. The counseling and/or risk factor reduction intervention code family describes counseling in 15-minute increments.

When a pediatrician provides preventive medicine counseling at a preventive medicine service, you should report only the preventive medicine service (99381-99385 for new patients and 99391-99395 for established patients). Preventive medicine services include counseling/anticipatory guidance and risk factor reduction provided at the same encounter, according to-CPT's preventive medicine services introductory notes.

Not being able to charge 99401 with 99381-99385 or 99391-99395 probably won't hit your pocketbook. "Most plans consider 99401 a non-covered service," says Nancy Reading RN, BS, CPC, director of education for the American Academy of Professional Coders in Salt Lake City. "I would not bank on seeing extra revenue for this [code]."

Good news: "Some payers, such as Ohio Medicaid, may cover 99402-99404 when billed at a separate encounter from 99381-99385/99391-99395 for anticipatory counseling guidance when the physician addresses issues such as diet and obesity prevention," Tuck says. For instance, Ohio Medicaid covers the longer counseling sessions (99402-99404), but not the shorter (99401), he points out.

Question: Do these annual assessments entail any new work?

Answer: No. "The new goals, in my opinion, are merely stating what should be done in every well-child checkup," says Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J.

These new "guideline recommendations" should not create additional work for pediatricians who provide proper quality of care in their preventive medicine services, Scott says.

An annual physical already addresses the recommended aspects -- dietary habits, physical activity (and "why not" if the patient is inactive), growth and development including plotting height and weight, determining body mass index (BMI), along with anticipatory guidance after the complete physical examination.

Question: Should you avoid labeling a patient during an assessment as overweight or obese?

Answer: No. In fact, the AMA promulgates stricter guidelines for overweight and obese diagnoses use. Classify children whose size puts them at or above the 95th percentile on the pediatric growth charts or who have a body mass index (BMI) higher than 30 as obese. Consider children who are between the 85th and 95th percentile overweight, say recommendations from the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity, released June 6.

In these cases, use the overweight/obesity diagnosis followed by the BMI diagnosis, as ICD-9 sequencing instructions state. For an obese child, use 278.00 (Obesity, unspecified) and V85.54 (Body Mass Index, pediatric, greater than or equal to 95th percentile for age). Code "overweight" as 278.02 and V85.53 (Body Mass Index, pediatric, 85th percentile to less than 95th percentile for age).

Take-away tip: These diagnoses establish a distinct problem that could lead to more pay. If during the preventive medicine service, a pediatrician diagnoses the patient as overweight or obese and performs the key components of a problem-oriented E/M service for this separate problem, he should report an office visit code (99201-99215) in addition to the preventive medicine service. The AMA-recommended ordering and reviewing of lab work related to that diagnosis supports a separately billable E/M service. Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to indicate the office visit is significant and separately identifiable from the well-related service. Link the office visit to the supporting ICD-9 code, such as 278.00 and V85.54 for obesity or 278.02 and V85.53 for overweight. When treating the disease in the future, the pediatrician can use follow up and regular sick visit codes, Reading says.