Pediatric Coding Alert

Adolescent preventive medicine exams for patients 12 to 17 years old can include ancillary and gynecological services that may not be covered in comprehensive preventive care exams, so pediatricians should be vigilant about recording any additional services they provide during these exams and clearly document services.

The key to correctly coding adolescent preventive E/M exams is understanding what comprehensive preventive medicine services include, coding experts stress.

You should use 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, new patient; adolescent [age 12 through 17 years]) for new adolescent patients who are 12 through 17, according to CPT.

Report 99394 (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 appropriate immunization[s], laboratory/diagnostic procedures, established patient; adolescent [age 12 through 17 years]) for established 12- to 17-year-old patients.

If the patient is 18 years of age or older and is a new patient, use CPT 99385 for an initial preventive medical evaluation. Report 99395 for established patients who are 18 or older.

In addition to the history and physical examination, 99384 and 99394 include counseling and risk-reduction intervention. During the exam, if the pediatrician determines that an adolescent needs guidance for any kind of problem, he or she may offer advice during the same office visit. Typically, pediatricians counsel adolescents during checkups on such issues as family problems, drug abuse, and sexual practices, says Kevin Perryman, practice administrator for Primary Pediatric Medical Association of Seguin, Texas.

If the adolescent sees a pediatrician just for counseling and does not have a preventive medical exam, however, you would not use 99384 or 99394. Instead, report 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes), 99402 (... approximately 30 minutes), 99403 (... approximately 45 minutes) or 99404 (... approximately 60 minutes), depending on the counseling session's duration.

Indeed, the preventive, risk-reduction counseling codes are not the same as those for counseling patients with established medical problems, so make sure you're clear regarding the reason the physician counsels an adolescent, coding experts warn.

For instance, you would not use 99401-99404 when an adolescent has an established problem, says Richard Tuck, MD, FAAP, practicing pediatrician with Primecare Pediatrics of Zanesville, Ohio. Use these codes when the pediatrician provides general preventive counseling for a patient who may need advice on such issues as birth control or substance-abuse prevention.

When an established patient is having psychological problems and needs counseling, however, there are several coding options. The most efficient approach is to report the established patient office visit codes (99212-99215) based on time spent with the patient during a counseling session, Tuck says.

Most pediatricians do not routinely include gynecological services, such as pelvic exams and Pap smears, as part of the comprehensive preventive medical exam.

Whether an adolescent girl receives gynecological services as part of a pediatric comprehensive preventive exam depends on several factors: if she is sexually active and if the additional time needed to complete such procedures as a pelvic exam and Pap smear can be scheduled during the comprehensive preventive exam.

The new recommendation on Pap smears by the American Cancer Society is that the patient does not need her first Pap smear until three years after the onset of sexual activity. So a Pap smear in the first three years really isn't necessary, says Robert Brown, MD, professor of clinical pediatrics at Ohio State University College of Medicine & Public Health and head of the adolescent health department at Children's Hospital in Columbus.

But sexually active girls should have pelvic exams to screen for sexually transmitted diseases (STDs), Brown says. He notes that increased availability of STD urine screening may reduce the need for pelvic exams for STD screening.

If a nonsexually active girl has no gynecological disease symptoms such as abdominal pain or unusual vaginal discharge, the pediatrician may decide she still needs contraceptive and STD counseling as a risk-reduction intervention.

Some patients are sexually active but will tell pediatricians that they aren't, particularly if the patients don't know the physician well. Consequently, some physicians will provide risk-reduction counseling anyway, Perryman says. In this case, you would report 99384 or 99394 because the contraceptive/STD counseling is part of a preventive medical exam.

When a patient has a comprehensive preventive exam that also involves treatment for a minor gynecological abnormality such as vaginitis (616.10), you would report 99384 or 99394 and 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 that the pediatrician performed two distinct E/M procedures on the same day, Tuck and Perryman say.

Remember that when you use modifier -25 on an E/M code for additional services at the time of a new patient visit, you always use the established patient E/M codes (99211-99215) for the separately identified problem, Tuck says.

You should also link the E/M code to the appropriate diagnosis code. For instance, if the physician diagnoses the patient with vaginitis during a comprehensive exam, you would link 99384 or 99394 to V20.2 (Routine infant or child health check), and link 99212-99215 to 616.10 (Vaginitis).

CPT's comprehensive preventive exam description in 99384 and 99394 does not exclude pelvic exams from the comprehensive services, so technically the pediatrician would bill 99384 or 99394 for the comprehensive exam, which includes a pelvic examination. The physician should report diagnosis codes V72.3 (Gynecological examination) and V76.47 (Special screening for malignant neoplasms, vagina) if the patient has a Pap smear.

If the pelvic exam is part of the comprehensive preventive examination, however, the physician would lose reimbursement for the extra work the pelvic exam requires. Unless the patient returns for a pelvic exam in a separate visit, there is no way of capturing the extra pelvic exam work.

"Frequently, we break the routine health maintenance exam and routine gynecological exam into two visits and bill separately for each visit," Brown says. "We do this if an adolescent is asymptomatic and just needs routine screening for STDs, such as tests for gonorrhea (V74.5) and chlamydia (V73.x)."

If the patient does return, you should use E/M codes 99213 or 99214, depending on the time spent, with V72.3 for the gynecological exam, and diagnosis codes for Pap smear (V76.47) and STD screening (V74.5), as appropriate.