Pediatric Coding Alert

Don't write off payment for injections, screenings, and other services during preventive exams.

When a patient presents to your practice for a preventive medicine visit, you'll simply report a code from the 99381-99397 range and move on, right? Not so fast. You could be writing off hundreds of dollars in reimbursement for the additional services you provide at checkups. Find out what you can separately report by reading the following five tips.

Note: Although CPT® does not recommend modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the preventive medicine E/M codes for any of these services, some payers may require this for separate recognition and payment. The following discussions and examples may require you to append modifier 25 to the preventive medicine codes.

1. Problems Discovered During Well Visit.

If you encounter a significant problem or abnormality during a preventive medicine visit, you can separately report your treatment of that problem. You'll report the appropriate preventive medicine code from the 99381-99395 range with modifier 25 appended, followed by the procedure code. Although poorly covered in the past, most payers are now recognizing and paying for these separate significant services addressed at preventive medicine visits.

Example 1: A 12-year-old established patient comes in for a preventive medicine service (99394, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/ diagnostic procedures, established patient). During the visit, the boy points out a lump on his foot. The physician diagnoses a wart and offers to remove it with cryotherapy (17000, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], all benign or premalignant lesions [e.g., actinic keratoses] other than skin tags or cutaneous vascular proliferative lesions; first lesion). The boy's mother agrees, and the pediatrician treats with liquid nitrogen. You should code the case with 99394-25 and 17000. Link diagnosis code V20.2 (Routine infant or child health check) with 99394, and link 078.10 (Warts plantaris) with 17000.

Example 2: The physician performs a preventive medicine visit on a 9-year-old girl (99393). During the visit, he also reevaluates her ADHD and adjusts her medication. Therefore, you'll report 99393 linked to V20.2 for the preventive medicine visit, along with a problem-based E/M code such as 99213-25 linked to 314.01 for the ADHD. You'll most likely select the problem-based E/M code on the amount of time spent counseling the patient related to the ADHD problem.

Tip: To determine whether you are justified in billing problem-based E/M code along with the preventive medicine code, keep these four criteria in mind, advises Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "If the problem is significant enough that it would require the patient to come back for another issue if you didn't address it, that's a sign that it could warrant a problem-based E/M code," Tuck says. "In addition, check whether the problem-based visit has its own ICD-9 code. Also, these separate visits typically require some evaluation and treatment such as x-ray or lab tests, and may require a prescription," says Tuck.

2. Immunizations

If your physician administers vaccines on the same day as a well visit, report the preventive visit with the appropriate code such as 99391 and separately report the appropriate immunization administration code (such as 90460). Although not required by CPT®, you might need to append modifier 25 to the preventive medicine code, depending on the payer's guidelines.

Example: A pediatrician performs a complete well visit on a 15-month-old patient, and counsels the mother on vaccine risks and benefits prior to giving the patient a DTaP-vaccination. The diphtheria, tetanus and pertussis each count as one component. For the vaccine administration with counseling on the components included in the DTaP, report one unit of 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component) and two units of +90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine/toxoid component). You'll also report the appropriate preventive medicine code, such as 99391. You'll link V20.2, Routine infant or child health check to all of the codes billed, because vaccinations link well to V20.2 and you do not need to link the vaccines to a separate ICD-9 code. Therefore, your claim will look like this:

• 90460 linked to V20.2
• 90461 x 2 linked to V20.2
• 90700 (Diphtheria, tetanus toxoids, and acellular pertussis vaccine [DTaP], when administered to individuals younger than 7 years, for intramuscular use) linked to V20.2
• 99391-25 linked to V20.2

3. Additional Injections

You may perform a well child visit that doesn't require vaccine administration, but does require other injections. In these cases, you should still report the injection code with the preventive medicine visit.

For example: Your nurse administers a Synagis injection to a premature baby during a well child visit. In this situation, you'll report the appropriate preventive medicine code with modifier 25 appended, along with 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) to complete the claim.

Link your Synagis diagnosis to 765.10 (Prematurity), and link the preventive visit code to V20.2.

Don't forget: If you are paying for the Synagis, you should also bill for the product. Report 90378 (Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each).

4. Laboratory Tests

When you perform a preventive visit, you cannot also bill for the pediatrician's work ordering lab tests. However, if your practice performs those tests in-house, you can separately bill for them along with your preventive medicine code.

Example: For instance, if the physician runs a lab test to check the patient's hemoglobin, you can report 85018 (Blood count; hemoglobin) and also bill for obtaining the specimen (36416, Collection of capillary blood specimen [eg, finger, heel, ear stick]). Again, modifier 25 may be required by the payer on the preventive medicine code.

5. Hearing, Vision, and Behavioral Screenings.

Bright Futures guidelines support various types of screenings along with preventive medicine visits, which may include vision, hearing, and developmental testing. You can separately collect from most payers for all of these screenings.

For example: You perform a preventive medicine visit on a nine-month-old patient, and also perform standardized developmental testing on the infant. You'll report 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) with the preventive medicine code. Append modifier 25 to the preventive medicine service code.

Likewise, if you perform a hearing screening, you'll report the appropriate code, such as 92551 (Screening test, pure tone, air only). For vision screening, you'll report 99173 (Screening test of visual acuity, quantitative, bilateral). In most cases, you'll have to append modifier 25 to the preventive visit code when billed with these services.