Pediatric Coding Alert

Pediatricians who perform pelvic exams on teens must code carefully to avoid fraud while maximizing reimbursement for this time-consuming service. Ironically, there is no CPT code for a pelvic exam. However, coding solutions such as using high-level E/M codes can facilitate reimbursement.
 
"Pediatricians have difficulty choosing procedure and diagnosis codes for a pelvic with no symptoms," says Thomas A. Kent, CMM, CPC, president of Kent Medical Management in Dunkirk, Md. Below are the circumstances, with coding recommendations, under which pediatricians perform pelvic exams.

Simple Exam During a Well Visit

 
A pelvic exam is included in a visit for preventive-medicine service: 99384 (new patients ages 12-17), 99394 (established patients ages 12-17), 99385 (new patients 18-39) or 99395 (established patients 18-39). You cannot bill separately for a pelvic exam unless the patient has a medical problem or complaint. Then you can bill a sick visit (99201-99205 for a new patient, 99212-99215 for an established patient).
 
For example, if the pediatrician performs a complete preventive-medicine service (well visit) and a pelvic exam because the patient is sexually active, report only the appropriate preventive-service code. Do not report the pelvic exam separately as a sick visit. Use ICD-9 code V20.2 (routine infant or child health check) with the well visit.

Use Specialized Codes

 
A Pap smear with a pelvic exam, for a child with no medical complaints, should be coded V72.3 (gynecological examination). "Do not use V20.2," Kent says.
 
Sometimes pediatricians feel they shouldn't use ob/gyn codes like V72.3. But physicians should use the correct diagnosis codes, notes Richard H. Tuck, MD, FAAP, founding chairman and a member of the AAP coding and reimbursement committee. "Be sure to follow carrier-specific guidelines regarding Pap smear and pelvic exam codes. But if a pediatrician performs a Pap smear, he or she should charge for it using the correct diagnosis code (V72.3)," Tuck says, comparing this situation to a family practice physician who performs a c-section even though the physician is not an ob/gyn.
 
Pediatricians, however, can't report the preventive-medicine services codes for purely gynecological exams. Instead, they should bill an office visit (99201-99205, 99212-99215) for a gynecological exam, Tuck says.
 
For example, a teen-age girl comes in for a gynecological exam and has no medical complaint. Perhaps she wants birth-control pills. Bill an office visit (i.e., 99213 or 99214), linking it with V72.3. If counseling predominates the session, the pediatrician can select the level of E/M based on time.

Coding Medical Problems

 
If the patient needs a pelvic exam due to a medical complaint such as abdominal pain, report an E/M service with the symptom or condition listed as the diagnosis.
 
"The best way to code a problem visit with a pelvic exam may be 99215, with the appropriate diagnosis," says Charles Schulte III, MD, FAAP, the AAP's representative on the AMA's CPT advisory committee and chairman of the AAP coding and reimbursement committee.
 
For example, a 15-year-old girl presents with acute abdominal pain and dysuria. She has a history of urinary tract infection and on private questioning says she is sexually active. She has not had vomiting, diarrhea, urinary urgency or frequency, and denies a vaginal discharge. She has a fever of 101, is unable to stand up straight, and is tearful. Her mother is anxious to discuss her daughter's problems.
 
A physical exam done with a nurse present reveals acute midlower and lateral abdominal pain with mild rebound. The pelvic exam reveals a cervical discharge, erythema and marked tenderness on movement of the cervix.
 
The pediatrician takes cultures for sexually transmitted diseases, as well as a blood count, pregnancy test, urinalysis and urine culture.
 
With permission from the patient, the physician discusses with her and the mother the diagnosis (614.9, pelvic inflammatory disease), a treatment plan with antibiotics and the need for treatment of the boyfriend. Pregnancy prevention and risks of sexually transmitted diseases are discussed. The mother is encouraged to be supportive and understanding. A follow-up visit is planned in one to two weeks.
  
The time spent on this visit is 45 minutes; counseling time is 25 minutes. Reporting 99215 is justified based on the amount of time spent counseling and coordinating care.
 
When billing an E/M service for a medical condition, you can include a pelvic examination and if the physician spends more than 50 percent of the encounter time counseling, coders can determine the E/M level based on time.

When To Use Modifier -25

 
If a patient presents for a well visit but has a separate identifiable problem that calls for a pelvic exam, pediatric offices can bill for both services (well and sick visits) by appending modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the sick visit code.
 
For example, a 16-year-old sexually active girl presents for a well visit and complains of painful menstruation. The pediatrician performs the complete preventive-medicine services exam (99384) and links it to V20.2. The pediatrician also evaluates the painful menstruation (9921x-25) and links 625.3 (pain and other symptoms associated with female genital organs; dysmenorrhea) to the office visit code.

Should You Reschedule?

 
Sometimes, to avoid the scheduling problems of an unplanned pelvic exam added to a well visit, the pediatrician will ask the patient to come back another day, either for the well visit or for the pelvic exam.
 
Scheduling well visits and pelvic exams on different days to simplify billing and reimbursement is not ethical. Do not automatically have a patient come back another day for a well visit or a pelvic exam; do this only when the schedule is too full to perform both services at the same time.

Coding for Contraception Management

 
Often, when a patient is sexually active, she requests contraception. If this is a stand-alone visit and she has no medical complaint, there is no CPT code that accurately describes the service. Coders can bill an E/M service with a code from the V25.xx series (encounter for contraceptive management) as the diagnosis, but because the patient has no medical complaint, the payer may deny the claim.
 
If the patient presents with a medical problem that is associated with the contraception, such as nausea or breakthrough bleeding, report an E/M visit and link it to the appropriate ICD-9 code for the medical complaint.

Respect Confidentiality

 
Explain to the patient that if the insurance company will not pay for the visit, a bill will be sent to her parents. If you are up-front with her about payment, she may choose to pay herself.
 
However, some pediatricians choose not to bill the parents if there is a concern about confidentiality. Instead, they choose to write off the visit because of their longstanding relationship with the family, Tuck says. While not beneficial to the bottom line on a short-term basis, this policy can benefit the practice's long-term customer relations with the family, which may have younger children as well.