Pediatric Coding Alert

This series helps show why $64 more for a 99214 could be in order.

Still don’t have Z62-Z63 series on your superbill? Your E/M levels could be suffering.

Pediatricians frequently deal with dysfunctional families, and the Z62 (Problems related to upbringing) and Z63 (Other problems related to primary support group, including family circumstances) groups can support work done within these codes’ described issues.

Using a counseling diagnosis often supports a higher level of CPT^® coding for these time-dominated visits.

Discover 7 Disruption Types

Family visits can encompass a variety of situations, and many of them warrant a “Z” code to describe the circumstances. For instance, an encounter needed for a family member on military deployment would warrant reporting Z63.31 (Absence of family member due to military deployment). This could apply if the patient is having sudden issues with sleeping, OCD or other problems when her parent deploys. If, however, the family presents for a visit to discuss issues that have surfaced after the parent returned from deployment, Z63.71 (Stress on family due to return of family member from military deployment) would be more accurate.

Other codes include disruption due to the following circumstances:

• Z63.5 – Disruption of family by separation and divorce
• Z63.4 – Disappearance and death of family member
• Z62.21 – Child in welfare custody
• Z62.81_ – Personal history of abuse in childhood (add a sixth digit to denote the type of abuse, such as Z62.812, Personal history of neglect in childhood)
• Z63.8 – Other specified problems related to primary support group (includes issues such as “inadequate family support NOS,” “family estrangement,” “family discord” and more).

Look for Counseling Session’s Condition, Percentage

You’ll find significant potential for using the family disruption codes in counseling sessions regarding divorce, foster care, military parents, etc., and should apply these codes to describe to the insurer exactly why the visit was necessary.

What CPT^® codes could you use for a family disruption counseling session? Typically, you’ll report an E/M code such as 99201-99215 for a family visit. Remember that the descriptor for these E/M codes says that the visits in this category can involve time “with the patient and/or family.”

Before reporting these services, consider these requirements:

• E/M level: If the counseling and/or coordination of care dominates (more than 50 percent) the physician/ patient and/or family encounter (face-to-face in office or other outpatient settings), time can be the key or controlling factor to qualify for a particular level of E/M service, such as 99201-99215. Documentation must include the encounter’s total face-to-face time, counseling time, and a brief discussion summary.

Example: A mother asks a pediatrician to talk to her daughter about an impending divorce and to discuss the custodial arrangements. The physician spends 10 minutes gathering the history of the divorce and asking questions about the patient’s health. He then spends 15 minutes counseling the parent and patient on her concerns, fears, and anger, and documents “spent 15 total minutes counseling on managing feelings during upcoming divorce and changed living arrangements. Total visit time is 25 minutes.”

Based on the performed and documented history, examination, and medical decision making, the visit qualifies as a level-two established-patient office visit (99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making … Physicians typically spend 10 minutes face-to-face with the patient and/or family).

However, because counseling comprised more than 50 percent of the encounter’s total face-to-face time, you instead can select the E/M level using time as the controlling factor, resulting in a claim for code 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity … Typically, 25 minutes are spent face-to-face with the patient and/or family).

Reporting Z63.5 for this service helps support the visit’s higher level of 99214 which equates to approximately $64 more in pay than 99212, which you would have reported if you hadn’t billed based on time spent.

Medicare’s 2016 Physician Fee Schedule, which can be used as a benchmark for private payers’ rates, pays 99212 nationally at $44, while it reimburses 99214 at about $108.

Recognize Other Z62 and Z63 Encounters

You’ll sell yourself short if you limit family disruption ICD-10 codes to counseling sessions. You might find Z62 and Z63 beneficial when a patient seeks or receives medical advice or care due to family disruption. If the physician uses an E/M code, there could be other diagnoses, such as stress (for instance, F43.0, Acute stress reaction) and/or depression (for example, F43.21, Adjustment disorder with depressed mood). “You might also want to look at the ‘Signs and Symptoms of an Emotional State’ series to see if any of those diagnosis codes apply as well,” says Donelle Holle, RN, practice administrator with Fort Wayne Pediatrics and President of Peds Coding, Inc. “If so, use the specific code as primary and then the Z code as secondary.”

Don’t miss: You’re free to couple the ‘Z’ codes with another ICD-10 code, as appropriate. For example, a teenager who is was recently removed from her home by child welfare officials has been experiencing fatigue and weight loss. During an office visit, the pediatrician diagnoses her with depression caused by her living situation. The physician assigns a level-four established-patient visit based on performed and documented key elements of history, examination, and medical decision making.

This type of visit could support 99215 (… a comprehensive history; a comprehensive examination; medical decision making of high complexity … Physicians typically spend 40 minutes face-to-face with the patient and/or family) if the total visit is 40 minutes and total face-to-face time counseling on the diagnoses related to depression, child welfare removal from the home, and other diagnoses. For the diagnoses, you would submit fatigue (R53.83), weight loss (R63.4), depression (F32.9), and Z62.21.