Pediatric Coding Alert

Often, the first time a child is seen in a pediatric practice is when he or she is sick. Some pediatricians opt to do a preventive medicineservices visit at that time as well. How should you code that visit? asks Kelley Hughes, insurance director of Queen City Physicians, a seven-pediatrician practice in Cincinnati, OH. A lot of times our patients are seen in our office for an illness on their first visit, she adds.

The answer, says Brenda Smith, clinic supervisor for Southern Oregon Pediatrics, an eight-pediatrician, one-nurse practitioner practice in Medford, is to code the visit based on what was done. Our pediatricians code their own visits, Smith explains. If they do a complete preventive-medicine visit, theyll code it that way. If the child was sick, too, and it was out of the realm of what they would do during a well visit, they will use an office-visit code (new patient office visit, 99201-99205) with a -25 modifier attached, as well as a preventive-medicine visit code.

If the problem is severe enough, the pediatrician will code the sick visit a level four (CPT 99204 ), says Smith. But she notes that its not correct to upcode simply because the patient hasnt been seen before. There are office visit codes for new patients, and they have higher relative value units (RVU) than the office visit codes for established patients, in terms of respective levels to compensate the physician for the expected increase in work for seeing a new patient.

If a well visit and a sick visit are done at the same time for a child who is a new patient, you would use the new patient codes for both. The preventive medicineservices codes for new patients are 99381 (under 1 year old), 99382 (1 through 4), 99383 (5 through 11), 99384 (12 through 17), and 99385 (18 through 39). The office-visit codes are 99201 through 99205.

Note that the sick diagnosis code goes only on the office visit, and the well-care diagnosis code, V20.2, goes only on the well-care CPT code.

However, it often proves difficult to do a preventive-services exam if only a sick visit has been scheduled, Smith notes. This is because less time is set aside for the office sick visit than would be for the well visit, and for many practices, well visits need to be scheduled in advance.

If you see the patient for the sick visit, and schedule a preventive medicineservices exam for a later date, you must use the new patient code for the sick visit, and an established patient code for the preventive medicalservices visit that will follow. For example, if the child gets a level three sick visit for his or her first visit, you would use 99203. For the well visit provided later, you would use 99391 for under one year, 99392 for 1 through 4 years, 99393 for 5 through 11 years, 99394 for 12 through 17 years, and 99395 for 18 through 39 years.

Billing the Parent

There would also be questions about what insurance plan the child was in, says Smith. If its a capitated Medicaid plan, we would make sure that they were actually covered under that plan before we saw them, she says. And we would make them sign a waiver so that we could bill them if the claim was denied, she adds, noting that the practice cant bill Medicaid patients who are in private HMOs, unless theres a signed waiver in the chart.

If, however, the plan is a commercial PPO, Smith wouldnt need a waiver before seeing the new patient. We can bill the parent if the claim is denied if its a commercial, non-capitated plan, so we dont have to get a waiver then, she says.