Pediatric Coding Alert

Get the scoop on in-house blood testing codes.

In the world of pediatric medicine, preventive services play a substantial role. As coders, you need to be able to understand how to report these preventive services accurately every time.

In her HEALTHCON 2024 presentation, “An Ounce of Prevention is Worth a Pound of Cure,” Christine Hall, CHC, CDEO, CPC, CPB, CPMA, CRC, CEMC, CPC-I, CEO and senior consultant at Stirling Global Solutions LLC took time to explain pediatric preventive services and how to ensure they are coded properly.

Understand Bright Futures Milestones

“The American Academy of Pediatrics [AAP] put together this amazing Bright Futures list,” explained Hall (https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf). Bright Futures is a national health promotion and prevention initiative that has helped standardize and improve the quality of pediatric preventive care. This set of standards focuses on the child’s overall well-being, including their physical, emotional, and social health. It’s this holistic approach that has providers more consistently paying attention to not only milestones for growth and development but also early detection of potential health issues.

“There are milestones we need to be checking… and providers know there’s an expectation based on this list. It’s important,” Hall said.

Correct Coding: As you know, there is a host of preventive service care CPT^® codes, and many of them are age specific. To help you match each age-specific preventive service with the correct code, Jan Blanchard, CPC, CPEDC, CPMA of Vermont-based Physician’s Computer Company, put together this Bright Futures-based coding chart in 2017 (https://learn.pcc.com/wp/wp-content/uploads/2017_CodingForBrightFuturesPe­riodicitySchedule.pdf) for easy reference.

Medicaid alert: If your provider participates in the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Medicaid program, they are required to provide EPSDT services to eligible individuals under the age of 21. Coding for this service may require HCPCS code S0302 (Completed early periodic screening diagnosis

and treatment (EPSDT) service (list in addition to code for appropriate evaluation and management service)). Many states use the Bright Futures guidelines to shape the schedule of screenings and services provided under the EPSDT program. However, these regulations do vary, so check with your state’s Medicaid agency for specific requirements.

Know What Constitutes Abnormal Findings

To code a routine child health exam, you first need to know whether to code the encounter with Z00.121 (Encounter for routine child health examination with abnormal findings) or Z00.129 (Encounter for routine child health examination without abnormal findings. Many providers don’t have a firm grasp of what an abnormal finding is during a preventive visit, which is a misunderstanding that commonly trickles down to coders.

“What did you find? Did you know about that before they came? Yes? That’s not a finding,” says Hall. “If it wasn’t found today, it’s not a new finding,” she continued.

For example: Let’s say the pediatrician discovered an upper respiratory issue during the preventive encounter. That would be considered an abnormal finding. However, if the child’s previous visits have indicated similar issues and the doctor is actively monitoring them, then that would not be considered an abnormal finding during the well visit, even though upper respiratory issues deviate from what is considered “normal.”

Don’t Overlook Laboratory Testing

According to the US Preventive Services Task Force (USPSTF), bilirubins, lipid panels, cholesterol, triglyceride, and hepatitis screenings, are covered by all payers. “Also lead screenings, newborn metabolic tests, we do these according to the Bright Futures chart,” said Hall. This means becoming familiar with and using some of the following CPT^® codes and their corresponding diagnosis codes.

Lead and Screening: For lead screenings, which the USPSTF recommends at 12 months, report Z13.88 (Encounter for screening for disorder due to exposure to contaminants) along with 83655 (Lead). Note that Z00.12- (Encounter for routine child health examination) might be a more appropriate ICD-10 code if the practitioner performs a preventive, age-based screening.

Newborn Metabolic Screening: When reporting a newborn metabolic screening with HCPCS Level II code S3620 (Newborn metabolic screening panel, includes test kit, postage and the laboratory tests specified by the state for inclusion in this panel (e.g., galactose; hemoglobin, electrophoresis; hydroxyprogesterone, 17-D; phenylanine (PKU); and thyroxine, total)), you’ll need to choose from the following ICD-10 codes:

• Z13.0 (Encounter for screening for diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism)
• Z13.21 (Encounter for screening for nutritional disorder)
• Z13.228 (Encounter for screening for other metabolic disorders)
• Z13.29 (Encounter for screening for other suspected endocrine disorder)

Note: Only report S3620 if you are billing for the actual test or running of the test kit. Otherwise, simply report the appropriate blood collection code, such as 36416.

Other Metabolic Tests: Report the following codes with Z13.228:

• 82247 (Bilirubin; total)
• 88720 (Bilirubin, total, transcutaneous)
• Report the following codes with Z13.220 (Encounter for screening for lipid disorders):
• 80061 (Lipid panel (This panel must include the following: Cholesterol, serum, total (82465) Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol) (83718) Triglycerides (84478))
• 82465 (Cholesterol, serum or whole blood, total)
• 83718 (Lipoprotein, direct measurement; high density cholesterol (HDL cholesterol))
• 84478 (Triglycerides)

Hemoglobin: Diet and other environmental factors heavily influence when or if a child should have a hemoglobin test, according to the USPTF. Code that encounter with Z13.0 along with CPT^® code 85018 (Blood count, hemoglobin).

Hepatitis: Report the following with Z20.5 (Contact with and (suspected) exposure to viral hepatitis) or Z11.59 (Encounter for screening for other viral diseases):

• 86704 (Hepatitis B core antibody (HBcAB); total) – 86707 (Hepatitis Be antibody (HBeAb))
• 87340 (Infectious agent antigen detection by immunoassay technique qualitative or semiquantitative hepatitis B surface antigen (HBsAg))

Report the following with Z20.5 (Contact with and (suspected) exposure to viral hepatitis) or (Z11.59 (Encounter for screening for other viral diseases):

• 86803 (Hepatitis C antibody)
• 86804 (Hepatitis C antibody; confirmatory test (eg, immunoblot))
• 87520 (Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, direct probe technique)
• 87521 (Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, amplified probe technique, includes reverse transcription when performed)

Caution: If the test is invoiced by an outside laboratory, do not report the lab code. Never report the laboratory code for a test the practice did not perform fully in-house.

And don’t forget: You can also bill for venipuncture using codes such as the following:

• 36406 (Venipuncture, younger than age 3 years, necessitating the skill of a physician or other qualified health care professional, not to be used for routine venipuncture; other vein)
• 36410 (Venipuncture, age 3 years or older, necessitating the skill of a physician or other qualified health care professional (separate procedure), for diagnostic or therapeutic purposes (not to be used for routine venipuncture))
• 36415 (Collection of venous blood by venipuncture)
• 36416 (Collection of capillary blood specimen (eg, finger, heel, ear stick))
• 99000 (Handling and/or conveyance of specimen for transfer from the office to a laboratory)