Pediatric Coding Alert

Preventive medicine services, the well visits that go from infant physicals through 65 years and over, and are coded by age, are not the same as office visits. Preventive medicine services are physicals, and as the name states, are meant to help prevent health problems; office visits are for problems.

In the old indemnity days, insurance companies didnt cover physicals. In those days, it was common for children who came in for physicals to get a diagnosis of dermatitis (a.k.a. diaper rash) so their parents could put the visit on their insurance. Then came the Evaluation and Management Services category of preventive medicine, and there were codes specifically for well-visits.

The preventive medicine services codes correspond with age groups. For a new patient, the codes are:

-- CPT 99381 (under 1 year old),

-- 99382 (age 1 through 4 years),

-- 99383 (age 5 through 11 years),

-- 99384 (age 12 through 17 years),

-- 99385 (age 18 through 39 years).

For an established patient:

-- 99391 (under 1 year old),

-- 99392 (age 1 through 4 years),

-- 99393 (age 5 through 11 years),

-- 99394 (age 12 through 17 years),

-- 99395 (age 18 through 39 years).

Most HMOs do cover preventive services -- or at least they have a plan that offers that coverage (although some parents may opt not to take it). Other plans dont cover it at all. What happens to patients whose insurance doesnt cover these codes? Either they have to pay out of pocket for physicals, their children simply dont get them, or their doctor codes physicals as an office visit -- just like the old days with the diaper rash.

The office visit codes are 99201 through 99215, and are not age-dependent.

Can you code a physical as an office visit? The simple answer is NO. If its scheduled as a physical, and its in the chart as a physical, and you do a physical, its a physical, says Victoria S. Jackson, administrator and CEO for Southern Orange County Pediatric Associates in Lake Forest, CA. No matter what you put as a CPT code, if the insurance company comes in and audits you -- as they have every right to do -- and they find out what youre doing, guess what? Youre in trouble. Its fraud.

Lets say you do a physical, in the course of which you detect an earache. Thats fine, says Jackson. But the primary diagnosis is still preventive medicine, and the secondary diagnosis is otitis. Adding extra codes wont do you any good on the reimbursement end either. Youre not going to get paid for finding an earache during a well-baby exam if the patients insurance doesnt have a provision for physicals, asserts Jackson.

Also, dont try to put a preventive medicine services code and an office visit code down at the same time. Thats multiple procedures, and you cant do it, states Jackson. Theyll downcode you to the lowest code anyway.

Okay, now for the complicated answer to the question, Can you code a physical as an office visit? People are doing it, so its obviously possible. Good luck to you until you get caught, is how Jackson puts it. It might be easier to get away with it with older patients, since their checkups arent that frequent. But from age two to age six, youre probably doing a physical every year, so it would be difficult to have annual office visits that look like real office visits. And it would be nearly impossible any younger than that. But even for the older children, an astute managed care organization would cry fraud, says Jackson.

They are truly auditing charts now, Jackson says of insurance companies. Theyll come in and see that you have charged them for an office visit, but it looks exactly like a well-baby visit.

This means that parents whose HMOs dont pay for physicals, or who could not afford to buy the plan that does, will have to pay out of their pockets for this care. Fortunately, Jackson reports, more and more HMOs are covering well-baby care. However, this is the kind of situation that makes pediatricians feel as if they are in a bind. Look who youre dealing with when your patients are young children, she says. People with limited resources. However, if you are faced with a fraud rap at the worst, or kicked off the plan panel at the least, you wont have anything at all to offer your patients.

So even the complicated answer is NO. Do not code a physical as if it were an office visit.