Pediatric Coding Alert

If you think your office might provide assessment and intervention, but you're not sure what scenarios warrant 96150-96155, try your hand coding these four situations:

Pediatrician Helps Child With Diabetic Anxieties

Scenario 1: A mother brings her diabetic son in to discuss his compliance problems. He refuses to take his insulin shot at school because he "wants to fit in." The pediatrician discusses why the insulin is essential to the child's well-being. For 30 minutes, he counsels the mother and child on peer pressure and ways to lessen the child's embarrassment.

Answer 1: In this case, you should use CPT 99214 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 25 minutes ...). A pediatrician, rather than a nonphysician, provides the service.

Select the E/M level based on time - 30 minutes in this case. Counseling comprises the majority of the visit.

Psychologist Assesses Athlete's Emotions

Scenario 2: A clinical psychologist on your staff assesses a child who has frequent sports injuries and long  recoveries. She interviews the 9-year-old all-star soccer player on stress, pressure to succeed and desire to play. During an hour session, she observes the child's responses and assesses the patient's behavior.

Answer 2: You should report 96150 (Health and behavior assessment [e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires], each 15 minutes face-to- face with the patient; initial assessment) x 4 units. Each unit represents 15 minutes of the psychologist's assessment of factors influencing the child's established illness - frequent bone fractures and sprains with prolonged healing periods and time away from sports.

RT Teaches Ways to Reduce Asthma Attacks

Scenario 3: A respiratory therapist (RT) in charge of as asthma disease management program spends 30 minutes with an asthmatic 5-year-old and his family. She discusses life-style issues that contribute to his frequent attacks and suggests ways that the family can help the child reduce the severity and number of incidences. She also demonstrates correct inhaler use.

Answer 3: Once again, the scenario qualifies for a health and behavior assessment/intervention code. A non-physician provides treatment to help a patient who has an established illness improve his well-being.

Since the intervention involves the family and the patient, you should use 96154 (Health and behavior intervention, each 15 minutes, face-to-face; family [with the patient present]). To account for 30 minutes of therapy, assign 96154 x 2 units. If the RT demonstrates correct inhaler use, you should also report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device).

Biter Joins Group Therapy

Scenario 4: A father presents at a pediatrician's office with his 2-year-old hearing-impaired son, who is biting other children. After interviewing, observing, monitoring and questioning the child and parent, the pediatrician concludes that the child is using biting to communicate. He suggests that the child join a play group for biters, which meets that night. A nurse runs the program.

Answer 4: CPT doesn't allow reporting E/M and intervention/assessment on the same day. So, you should only report the office visit (99201-99215) based on time spent and coordination of care in this situation.

When the child returns for subsequent group therapy without pediatric treatment, you may assign 96153 (... group [2 or more patients]).