Pediatric Coding Alert

Bring your E/M, vaccine coding up to date with this guide.

The good news is that, with just 182 additions, 49 revisions, and 74 deletions, the changes to the 2019 CPT^® manual are not particularly extensive. The even better news, if you’re a peds coder, is that there may not be a lot in these revisions to concern you.

But you still need to pay attention, as there are a number of additions to the evaluation and management (E/M) codes, especially those concerning telehealth and chronic care management (CCM) services, that may affect your coding. And there’s also a new flu vaccine code that you need to know about.

So, this overview will help you figure out which codes you may be reaching for when they are implemented on Jan. 1, 2019.

Ring in the Changes to Telehealth Coding

Two codes that could possibly get a workout in your practice are 99451 (Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time) and 99452 (Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified health care professional, 30 minutes).

You could possibly use 99451 if your pediatrician is called on to provide consulting services to another provider, while 99452 might help you document the work involved whenever a patient in your practice is referred out to a specialist. But how much use these codes will get in a pediatric setting remains unclear.

With 99451, for example, “primary care docs do very few consults anymore other than the occasional preoperative consult,” while referrals of the kind described by 99452 “are usually performed by clinical staff in an office, not the provider,” Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, points out. There’s also the practical consideration that, “currently, few payers reimburse for the telephone or internet CPT^® codes, so these may fall into the same category,” says Holle.

Get Ready for Changes to CCM

The other major E/M changes for 2019 concern CCM. Previously, care management for a chronically ill patient could only be documented when your provider supervised a care manager or a clinical staff member who was administering the patient’s care plan. For that, you would use 99490 (Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month ...).

However, if your provider directly administers the patient’s care plan, you will now be able to report 99491 (Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month …).

Coding caution: Aside from the credentials of the service provider, you’ll need to keep your eyes on the clock when you use either code. Code 99490 allows for “at least 20 minutes of clinical staff time … per calendar month,” while 99491 allows for an additional 10 minutes in that month.

Take Note of These New Ways to Record Data Management

Collecting a patient’s physiologic data is a critical component of CCM, so it should come as no surprise that the American Medical Association (AMA) has also taken the opportunity to delete one code and add several others related to this service.

Come Jan. 1, you will no longer be able to use 99090 (Analysis of clinical data stored in computers (eg, ECGs, blood pressures, hematologic data)). The code has been deleted altogether. But you can add three new codes to your CCM coding when you need to document data gathering:

• 99453 — Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
• 99454 — Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
• 99457 — Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

The codes reflect each step in the data collection process, from setting up the device and teaching the patient how to use it (99453), to supply of the device for daily recording or programmed alert transmissions (99454), to monitoring the data gathered and communicating any information and care plan revisions to the patient based on a provider or other qualified healthcare professional’s interpretation of the device’s data (99457). And both 99454 and 99457, like 99091, can only be reported once per calendar month to bring them roughly into line with the timeframe established by CCM codes 99490/99491.

These additions represent “an interesting step toward including IT-related monitoring of a patient’s chronic conditions,” according to Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.

But there are still many questions about their application in the pediatric setting. “They are probably going to be used for children with diabetes working with an endocrinologist, or for patients with heart problems working with a cardiologist and so on,” says Holle. And if they are used, “required documentation for these codes, such as the number of reports per month, signatures, which staff will review the results, and so on seems unclear,” says Johnson.

And Add This New Flu Code to Your Ongoing Vaccine List

Finally, in what seems to be an annual rite of passage, the AMA has added yet another CPT® code for a flu vaccine. Just in time for flu season, you’ll be able to report 90689 (Influenza virus vaccine, quadrivalent (IIV4), inactivated, adjuvanted, preservative free, 0.25 mL dosage, for intramuscular use).