Pediatric Coding Alert

Pediatricians can use counseling codes (99401-99404, 99411-99412) to talk to children and parents about guns and violence, but often they are not paid with these codes. You can get reimbursed for counseling on issues of violence by incorporating it into well-visits and office visits (99381-99385, 99391-99395).

Since January 1999, the American Academy of Pediatrics (AAP) has had a policy that urges pediatricians to address the issue of violence in children. In light of the recent tragedy of a 6 year-old Michigan boy shooting a classmate to death, it becomes even more imperative for pediatricians to step in. This doesnt only mean talking to the parents about removing handguns from the home, it means screening patients for violence-related risk factors and treating them for violence-related problems, at all ages and stages of development.

Here are the areas that the AAP encourages pediatricians to assess when trying to identify risk factors for violence.

History of mental illness, previous domestic
violence, or substance abuse in parents or other
family members.

Family stresses that could lead to violence (such
as unemployment, divorce or death).

Appropriate supervision and care and support
systems (such as child-care arrangements, the family, and social networks).

Disciplinary attitudes and practices of the parents or care givers (especially in terms of corporal
punishment and physical or emotional abuse).

Exposure to violence in the home (domestic
violence or child abuse), school or community.

Degree of exposure to media violence.

Access to firearms (especially handguns) in their
or a neighbors home, or the community.

Gang involvement or gang exposure in family,
school or neighborhood.

Situations in which the child or adolescent
experiences physical assault or sexual
victimization from anyone.

Signs of depression or poor self-esteem.

Other factors affecting risk, such as poor school
performance and physical, emotional or
developmental disabilities.

There is no way to bill for the extra time spent screening patients for violence risk factors; you must incorporate it into the visits, says Charles Schulte, MD, FAAP, the AAPs representative on the American Medical Associations (AMA) CPT Advisory Committee. Violence prevention is a part of anticipatory guidance, which includes issues such as household safety and car seats. We try to say something about guns and where the bullets are during the routine preventive health visit, says Schulte.

But if you do discover a risk, then you can handle the problem with office visits or office-based counseling, the AAP recommends. The pertinent codes for violence- prevention counseling are preventive-medicine services (99381-99385, 99391-99395) and a subset of preventive-medicine services: Counseling and/or Risk Factor Reduction Intervention codes (99401-99404, 99411-99412). Preventive-medicine services codes are usually billable only once a year in older children. Some HMOs will not pay the counseling codes at all; however, both sets of codes could be used for violence prevention.

According to CPT, preventive-medicine services should include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination. If you speak to individual patients at a separate encounter for the purpose of promoting health and preventing injury, you should use 99401 (15 minutes), 99402 (30 minutes), 99403 (45 minutes), or 99404 (60 minutes). If you speak to a groupa definite possibility for pediatricians who want to use their time wellyou would use 99411 (30 minutes) or 99412 (60 minutes). However, you may not get paid for the counseling codes, warns Schulte. Check with your carriers to see what method they prefer.