Pediatric Coding Alert

Stars deletion tops CPT 2004's simplification push

If you were thinking that the new CPT Codes Changes would further complicate your pediatric billing, think again. CPT 2004, effective Jan. 1, 2004, eliminates starred procedures, introduces new venipuncture requirements, clarifies after-hours reporting and updates vaccine codes - four changes that will simplify coding these services.
 
Here's what our experts say about applying these four changes:
 
1. Forget About Starred Procedures

In a move that will make surgical procedure coding easier and more consistent than before, CPT 2004 deletes the starred procedure designation, says Marie Felger, CPC, a coding consultant and American Academy of Professional Coders-certified coding instructor with Joy Newby & Associates LLC in Indianapolis. "You'll no longer have to think about handling surgical codes differently."
 
CPT previously used an asterisk to designate codes that contain the surgical procedure only, says Linda J. Walsh, MAB, division of healthcare finance and practice senior health policy analyst manager for the American Academy of Pediatrics (AAP) committee on coding and nomenclature in Elk Grove Village, Ill. Despite this designation, based on CPT's starred procedure guidelines, you still had to 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 established patient office visit codes (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) that involved significant identifiable services from a same-session procedure.
 
"The requirement seemed counterintuitive," Walsh says. Because a starred procedure contained no pre- or postprocedure work, a same-session E/M service should have been inherently separate from the surgery. Thus, CPT's modifier -25 requirement blurred the lines between a starred procedure and a nonstarred procedure, making the distinction unnecessary.
 
But some payers recognized starred procedures, says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif. For these insurers, you didn't have to use modifier -25 on an E/M code. If your pediatrician performed a starred procedure, such as wart removal (17000, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion), and an E/M service, for instance an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...), you didn't need to append modifier -25 to the procedure.
 
CPT's move, however, may cause insurers to stop accepting this billing method, which could cost pediatricians money, Jackson says. Unless payers increase previously starred procedures' relative value units to include associated pre- and postprocedure work, you'll still get the same reimbursement for the procedure. But you won't be able to recoup the E/M cost.
 
If the star's elimination causes modifier -25 rejections, you may want to consider using modifier -57 (Decision for surgery) when appropriate, Jackson says. For instance, in the above wart removal scenario, if the pediatrician performs a history, evaluation and medical decision-making, which leads to his decision to perform cryosurgery, you could append modifier -57 to the E/M code. The modifier indicates that the E/M service resulted in the decision for surgery. Plus, using modifier -57 has the added benefit of greater payer recognition, according to many pediatricians.
 
One thing you won't have to worry about is reporting 99025 (Initial [new patient] visit when starred [*] surgical procedure constitutes major service at that visit) for a new patient visit during which a starred surgical procedure constitutes the major service. The CPT panel deleted the code along with the starred procedure designation.

2. 36400 Requires a Physician's Skill

If you're unsure whether you should use 36400 (Venipuncture, under age 3 years, necessitating physician's skill, not to be used for routine venipuncture; femoral or jugular vein) for nurse venipuncture, CPT 2004 answers your question. You should use 36400 for venipuncture necessitating a physician's skill. CPT and the resource- based relative value system (RBRVS) always assigned physician work to 36405 (... scalp vein) and 36406 (... other vein), Walsh says. Now 36400's descriptor reflects that 36400 is for nonroutine venipuncture. The same requirement applies to 36410 (Venipuncture, age 3 years or older, necessitating physician's skill [separate procedure], for diagnostic or therapeutic purposes [not to be used for routine venipuncture]).
 
"When a nurse performs routine venipuncture, you should use 36415 (Collection of venous blood by venipuncture)," Walsh says. Make sure to assign 36416 (Collection of capillary blood specimen [e.g., finger, heel, ear stick]]) for a finger stick (new in CPT 2003).

3. Office Hours Determine 99050 Reporting

CPT finally clarifies that 99050 is for "services requested after posted office hours in addition to basic service." The addition of the word "posted" formalizes that you should use the adjunct code to describe services your pediatrician provides after established office hours, says Richard H. Tuck, MD, FAAP, AAP representative to the AMA RBRVS Review Update Committee.
 
The revised language indicates that you may assign 99050 in several situations. For instance, a pediatrician's office is closed on Wednesday afternoons. But a mother requests a 3 p.m. appointment for her child, and the pediatrician opens the office to see the patient. In this case, Tuck recommends reporting 99050 because the pediatrician provides a service outside posted hours, in addition to the E/M code (such as 99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...) you would report for the basic service.
 
You may also assign 99050 for evening appointments when the pediatrician sees patients after posted hours. Suppose a pediatric practice has posted hours of 8 a.m. to 5 p.m. At 5:15 p.m., the staff is still present because the doctors are running late. A patient calls and needs to be seen that evening. A pediatrician agrees to stay and treat the patient at 5:30. In this situation, you may now tack on the extra 99050 service.
 
Prior to 99050's revision, CPT was unclear regarding whether you should apply 99050 to an already open office. The change clarifies that you may assign the special service code as long as the patient requests an appointment after posted office hours.
 
Even though 99050's requirements are now black and white, some plans may still allow you to use 99050 for after-hours services, Walsh says. If an insurer realizes the savings that in-office treatment rather than emergency room care generates, it may allow you to negotiate contracts that permit billing 99050 during posted "nonregular" hours. For instance, a practice that has posted hours until 9 p.m. may be able to charge the after-hours fees after 5 p.m. Because this type of arrangement would be a contractual exception to CPT's rules, don't code this way unless you have a written agreement that spells out these terms.

4. Vaccine Section Gets an Update

You won't be using 90659 (Influenza virus vaccine, whole virus, for intramuscular or jet injection use) in 2004 because CPT deletes it to reflect the fact that the influenza whole-virus vaccine is no longer manufactured, Walsh says. You should report either 90657 (Influenza virus vaccine, split virus, for children 6-35 months of age, for intramuscular use) or 90658 (Influenza virus vaccine, split virus, for use in individuals 3 years of age and above, for intramuscular use) for the split-virus influenza vaccine. There are some new vaccine codes and a revision to established codes (90703-90708, 90718, 90727 and 90733) to delete references to "jet injection" as a delivery mode.
 
The Vaccines and Toxoids section also contains several new codes for 2004, including:

90655 - Influenza virus vaccine, split virus, preservative free, for children 6-35 months of age, for intramuscular use (Use this code for the pediatric intramuscular preservative-free influenza product FluZone.)

90656 - Influenza virus vaccine, split virus preservative free, for use in individuals, 3 years of age and above, for intramuscular use (Be careful: Although this code for adult FluZone is valid for reporting as of Nov. 15, 2003, 90656 won't appear in CPT until 2005.)

90698 - Diphtheria, tetanus toxoids, acellular pertussis vaccine, haemophilus influenza Type B, and poliovirus vaccine, inactivated (DTaP-Hib-IPV), for intramuscular use

90715 - Tetanus, diphtheria toxoids and acellular pertussis vaccine (TdaP), for use in individuals seven years or older, for intramuscular use

90734 - Meningococcal conjugate serogroups A, C, Y and W-135 (tetravalent), for intramuscular use.

Also, remember to use 90660 (Influenza virus vaccine, live, for intranasal use) for newly released FluMist.
 
Even though CPT 2004 is effective Jan. 1, 2004, not all payers update their systems on that date. To avoid denials, check with your insurers before using the codes. If you don't want to delay your billing, submit a copy of CPT 2004 showing the new or revised code.