Pediatric Coding Alert

AAP experts reveal how HCPCS Codes fill in CPT's gaps

Demystify level-two coding with these tips on using numeric versus alphanumeric codes. "Because some HCPCS codes duplicate CPT services and others don't, how can I tell which coding system to use?" asks Bonnie Palmer, billing manager at Tots N Teens Health Associates in Elgin, Ill.

To capitalize on the two systems, American Academy of Pediatrics (AAP) experts recommend that you answer the following three questions:

1. Does a CPT Code Describe the Service?

When a CPT code exists to report the service or product, you should use that code to obtain reimbursement, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. "Because CPT contains a code for every vaccine (90476-90748), you should always use the CPT version," she says.

On the other hand, if CPT doesn't define a service or product, the HCPCS code will allow for payment, Walsh says. For instance, since Rocephin and Albuterol lack a CPT code, fill in CPT's gaps with the HCPCS codes (Rocephin - J0696, Injection, ceftriaxone sodium, per 250 mg; Albuterol - J7618, Albuterol, all formulations including separated isomers, inhalation solution administered through DME, concentrated form, per 1 mg [Albuterol] or per 0.5 mg [Levalbuterol]; or J7619, Albuterol, all formulations including separated isomers, inhalation solution administered through DME, unit dose, per 1 mg [Albuterol] or per 0.5 mg [Levalbuterol]), she says.

2. Does HCPCS Offer a More Specific Code?

Because payers are more likely to reimburse specific codes, look for a HCPCS version when CPT contains a generic definition, Walsh says. Suppose your pediatrician gives a patient a new sling. Because HCPCS lists a more specific code (A4565, Slings) than CPT's generic supply code (99070, Supplies and materials [except spectacles], provided by the physician over and beyond those usually included with the office visit or other services rendered [list drugs, trays, supplies, or materials provided]), use the HCPCS alternative.

Stick with the CPT administration codes (90471, Immunization administration [includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections]; one vaccine [single or combination vaccine/toxoid]; and +90472, ... each additional vaccine [single or combination vaccine/toxoid] [list separately in addition to code for primary procedure]) even though HCPCS maintains G codes for specific vaccine administrations, such as G0008 (Administration of influenza virus vaccine when no physician fee schedule service on the same day) for flu shot administration, says Julia Pillsbury, DO, FAAP, a pediatrician at the Center for Pediatric Medicine in Dover, Del. After CPT created 90471-90472, CMS failed to follow the rules and remove the temporary G codes from the system, she says.

3. Are Insurers Paying You for the CPT Code?

If payers reimburse you for the CPT code, keep using the pediatrician-backed system, rather than the insurer-created (CMS, Blue Cross Blue Shield Association, the Health Insurance Association of America) HCPCS system, Walsh says. "If an insurer refuses to recognize the CPT code, try the HCPCS alternative," she says. "When our pediatricians remove sutures that another physician puts in, payers never recognize an E/M code (99201-99215, Office visit for the evaluation and management of a new or established patient ...)," Palmer says. In this case, try S0630 (Removal of sutures by a physician other than the physician who originally closed the wound), Walsh says.