Pediatric Coding Alert

Claim only solidly documented modifier 25 services

Two new care plan services codes solve the problem of billing telephone calls and care plan review for children not under a home health agency's care.

The AMA released the tentative agenda for its CPT 2006 Coding Symposium, to be held Nov. 17 and 18 in Chicago. The agenda gives the first official clues as to which areas next year's coding changes will address.

When the 2006 CPT updates take effect Jan. 1, 2006, pediatricians will face three major E/M changes. CPT 2006 will:

• introduce two new care plan oversight (CPO) codes that do not stipulate the patient must be under the care of a home health agency, hospice or nursing home

• clarify modifier 25's explanatory text to specify that documentation must support the significant and separate E/M claim

• delete follow-up inpatient consultation (99261-99263, Follow-up inpatient consultation for an established patient ...) and confirmatory consultation codes (99271-99275, Confirmatory consultation for a new or established patient ...). For information on consultation changes, see "Use Setting, Source to Assign Future Confirmatory Consult" in this issue and "New Year Rings in Fewer Inpatient Consultation Choices" later in this issue.

Note: All code changes for CPT 2006 are tentative and depend on approval by the AMA conference in November.

Here's what the changes mean to you.

Consider 993xx for Non-Agency Child Coordination

CPT 2006 will expand CPO services. "In 2006, CPO codes will no longer have the caveat that a home health agency, hospice or a nursing facility has to supervise the child's care," says Peter D. Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine in Brockton, Mass.

Current method: You may now report CPO services only when the patient meets one of three conditions:

• is under home health agency care--99374 or 99375

• is on hospice--99377 or 99378

• is a nursing facility patient--99379 or CPT 99380 .

"The new codes' introduction is very good news," Rappo says. CPO codes describe services that many special-needs children require.

Problem: "These patients are not always under the care of an HHA, a hospice or a nursing facility," Rappo says. Physicians will be able to use the new codes to report telephone calls, Internet communication, treatment plan revisions, and lab reviews for these patients.

Important: The AMA still has to determine the codes' last two digits. The panel now refers to the codes  as 993xx.

Reserve 25 for Documented Cases

You probably know that you should claim a modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) visit only when the pediatrician's documentation supports a significant and separate service. CPT 2006 will reinforce this guideline.

New modifier language: The update will clarify modifier 25's explanatory text. The new explanation will state that a "significant, separately identifiable E/M service" should have documentation that meets the requirements for the E/M service being reported. That means modifier 25 claims do not have to contain any new documentation criteria, says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Shrewsbury, N.J. "CPT is just clarifying that documentation must show the E/M service is significant and separate from the same-day procedure, preventive medicine, or other service."

This revelation comes as no surprise to coders. "Pediatricians should have been documenting modifier 25 services this way all along," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association with five offices in Lake Forest, Calif. "I always tell physicians that their documentation must support the E/M components of history, examination and medical decision-making as a stand-alone service from the procedure billed."

Action: To solidify your modifier 25 claims, use a separate written note for the E/M-25 code. In the entry, include the additional history, physical and medical decision-making. You may refer to the other service and other documentation as well.

Disadvantage: The new modifier language may encourage insurers to request supporting documentation before paying for the E/M-25 code on modifier 25 claims. So be prepared to send in chart notes substantiating your modifier 25 claim.