Pediatric Coding Alert

Change is inevitable, and for younger patients, one of those changes is transitioning from pediatric into adult medicine. Recently, the Centers for Disease Control and Prevention (CDC) posted an extensive list of ICD-10 changes set to take effect Oct. 1, 2022, and one particular new code, Z71.87 (Encounter for pediatric-to-adult transition counseling), is specific to this transition.

The following guide comprehensively breaks down everything you need to know to make the transition as smooth as possible for everyone involved.

Use These 6 Elements to Make the Change

Before we get into the new code, let’s first take the opportunity to review transition policies. Getting a solid process in place helps patients, caregivers, providers, and coders the tools needed to help patients move through the pediatric-to-adult transition seamlessly.

To aid in this effort, The National Alliance to Advance Adolescent Health, a national resource center on healthcare transition (HCT), updated its existing program and created the Six Core Elements of Health Care Transition™ 3.0 to help ease teenage patients into the world of adult medicine. Guidelines are available to accommodate three scenarios:

• Youth transitioning to an adult healthcare clinician
• Youth transitioning to an adult healthcare model while keeping their clinicians
• Integrating young adults into adult healthcare

The steps vary slightly for each scenario, but in essence the program outlines six elements to help your office facilitate the change:

• Establish a transition policy.
• Track and monitor the patient.
• Evaluate the patient’s readiness for the transition.
• Plan the transition.
• Transfer/integrate patient to an adult model of care and address patient concerns.
• Complete the transfer (Source: www.gottransition.org/ resourceGet.cfm?id=208).

“According to the American Academy of Pediatrics [AAP], the age of transition from pediatric well-care to adult well-care should be left up to the patient and/or family,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. “Fortunately, from a coding perspective, the transition need not be problematic, as either a pediatrician or other physician who provides such care need only know the age cutoff for the CPT® codes,” Witt elaborates.

Turn to Z71.87 for Transition Counseling

Since physician-to-patient discussion is inevitable as the patient moves from youth- to adult-oriented care, it makes sense that ICD-10 will now include a code specific to that encounter. Additionally, ICD-10 Official Guidelines will now include instructions on how to use Z71.87. The new code “should be assigned when pediatric-to-adult transition counseling is the sole reason for the encounter or when this counseling is provided in addition to other services, such as treatment of a chronic condition.”

These encounters can be quite comprehensive; potentially including discussions of everything from physical activity post-formal physical education to sexuality to relationship and family issues. Still, section I.C.21.c.10 goes on to explain that if the encounter addresses both counseling and treatment, sequencing will depend on the circumstances surrounding the treatment including the rules for applying the condition codes that are unique to the patient.

What Other Codes Come Into Play for a Simple Transition?

You’ll need to report the provider’s time with the patient so “depending on when this transition occurs, the codes best suited for such a service would be the preventive service codes,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. For many adolescent patients, that would happen during their final preventive medicine visit with their pediatrician.

That means “the codes that would most frequently be reported in this transition period by either the pediatrician or another provider type” would include 99384/94 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual …; age 12 through 17 years) or 99385/95 (… 18-39 years) according to Witt.

Use 96160 to Assess Patient Readiness

Along with 99394/5, you can also use 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument) to document that your pediatrician or staff member has administered a scorable transitional readiness form (such as the one featured on the “Got Transition” website at www.gottransition.org/6ce/?leaving-readiness-assessment-youth) to assess patients’ understanding of their own health, how to use the healthcare system, and their preparedness for the transition to adult healthcare.

Your staff can use the instrument regardless of whether the patient is new or established, and even though the code’s descriptor uses the words “risk” and “hazard,” you can use the code whether or not the patient suffers from a chronic condition. Just remember to add 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) to the E/M service to indicate that the preventive medicine visit is a separate service from 96160.

Moving Up Without Moving Out

Remember that not all transitions involve peds patients moving out of a pediatric practice. “The patient can stay within a practice, going from a pediatrician within the practice to an internal medical or family medicine provider,” Hauptman reminds coders. In this case, the patient would still be regarded as an established patient within the practice providing the patient meets the CPT® definition and has received “professional services … [in] the same group practice within the past three years.”

But “if the specialties are different, and the providers are enrolled as such with the payers,” according to Hauptman, the first adult patient service will meet the definition of a new patient visit.