Pediatric Coding Alert

Knowing what is, what is not, included is key.

Preventive services are the lifeblood of any pediatric practice and are, perhaps, the most important evaluation and management (E/M) services your pediatrician can provide to your young patients. But knowing what is, and is not, included in 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation and management of an individual …) has become the source of many coding myths.

So, we’ve busted some of the most common ones in this article to help you prevent coding errors and keep your claims clean.

Myth 1. The guidelines for a preventive service history and exam are the same for a problem E/M.

“The biggest mistake coders make when coding for preventive services is trying to fit the requirements of a preventive visit into the parameters for a problem E/M service — in thinking that a complete history or exam must meet Medicare E/M documentation guidelines, when in fact, only the CPT^® definition applies,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

So, to bust this myth, all you have to do is read the CPT^® descriptors for 99381-99396 closely, which state that the service includes “an age and gender appropriate history” and examination. In other words, the history and exam for a preventive visit “is not driven by either a chief complaint or a history of the present illness, but rather the requirements for the patient’s age and gender that relate to staying healthy,” Witt adds.

Myth 2. You must report any illness or abnormality discovered during a preventive visit exam.

This is another common problem coders make when billing 99381-99396.

“An insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service should not be reported separately,” Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts reminds coders.

However, “in cases when an illness or abnormality is discovered, or a preexisting worsening problem is addressed in conjunction with the physical, if the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, an appropriate E/M should be reported with modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service] in addition to the preventive medicine service code,” Walaszek continues.

Coding caution 1: “Keep in mind that some payers will not reimburse both a preventive and problem service on the same date of service,” says Witt.

Myth 3: Aside from vaccinations, most other services are not included in 99381-99396.

While most coders know that age-appropriate vaccines and vaccine administration can be reported separate from preventive service, many also believe that other services cannot be billed on the same date of service. In fact, nothing could be further from the truth.

“As documented in the Bright Futures/American Academy of Pediatrics [AAP] publication Coding for Pediatric Preventive Care, ‘Immunizations and ancillary studies involving laboratory, radiology, or other procedures, or screening tests [eg, vision, developmental, hearing] identified with a specific CPT^® code, are reported and paid for separately from the preventive medicine service code,’” notes Walaszek (See > www.aap.org/en-us/Documents/coding_preventive_care.pdf?utm_source=bright_futures_enews0315&utm_medium=email&utm_campaign=bright_futures_web_site).

So, all screenings can be billed separately, “including, but not limited to, Edinburgh post-partum depression screenings [96161], vision screenings [99177], hearing screenings [92552], ACT forms [96160], brief emotional/behavioral assessments [96127], and developmental screenings [96110],” Walaszek adds. (For a comprehensive list of age-appropriate screenings, go to  brightfutures.aap.org/materials-and-tools/tool-and-resource-kit/Pages/Medical-Screening-Reference-Tables.aspx).

Additionally, you can separately bill for blood draws and lab tests when they are performed for preventive purposes. Again, these could include, but not be limited to, age- and risk-appropriate tests such as:

• 82247 (Bilirubin, total) or 88720 (Bilirubin, total, transcutaneous)
• 83655 (Lead)
• 85018 (Blood count; hemoglobin (Hgb))
• 80061 (Lipid panel This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478)) or other appropriate dyslipidemia test
• 86580 (Skin test; tuberculosis, intradermal)
• 86701 (Antibody; HIV-1) or other appropriate HIV or sexually transmitted disease test
• 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional).

Don’t forget: You can bill a venipuncture code as well, when appropriate.

Coding caution 2: If your pediatrician collects a cervical specimen via a pelvic examination for pap smear purposes, the collection is included in the preventive medicine service code and you cannot bill it separately.

Coding caution 3: “Just because these services can be billed separately does not mean a payer will comply with reimbursement. Get to know your payers’ policies. That will help you determine which services you should review if denied and which ones are denied based on payer guidelines,” suggests Walaszek.

Myth 4: If the preventive service is not performed fully, you should still bill for it using modifier 52.

What happens when your pediatrician cannot perform a full and comprehensive preventive service?

One thing you cannot do is append modifier 52 (Reduced services) to the preventive code. “CPT^® has made it clear that a 52 modifier may not be appended to the preventive code, and the physician should pick the code that mostly closely supports the services performed,” cautions Witt.

“This may mean billing only a preventive counseling service from 99401-99404 [Preventive medicine counseling and/or risk factor reduction intervention(s) …] if no exam is performed or defaulting to an appropriate level of problem E/M service depending on the circumstance,” Witt suggests.