Pediatric Coding Alert

Question: How should we bill for patients who are under foster care and are being put in another foster home? They come in to be examined and cleared for new foster parents. We cannot bill a checkup if it's been less than a year from the last exam.

New Jersey Subscriber

Answer: You may consider several options for this visit based on the visit's specifics. If a clinical social worker or other appropriate source (see consultation article on page 74) requests the examination, and the pediatrician issues a written report with her findings, you may report an office consultation (99241-99245, Outpatient consultation). Because you are asked for your opinion, this is an acceptable coding method. Link the consultation to V70.3 (Other medical examination for administrative purposes), which includes an examination for adoption.

If the criteria for a consultation are not met and the child has no problems, report a preventive medicine code (99391-99397, Periodic comprehensive preventive medicine re-evaluation 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). Select the code based on the child's age and status, new or established patient. For example, a 10-year-old boy who is under the pediatrician's care presents with his foster mother for an examination, and no problems are found. Assign 99393 (... late childhood [age 5 through 11 years]) with a diagnosis code of V70.3.

If the child presents for a well visit and requires significant work for an illness or ailment, you may report the well visit and the sick visit. "If an abnormality/ies is encountered or a pre-existing problem is addressed in the process of performing this preventive medicine service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate office/outpatient code 99201-99215 should also be reported," states CPT in the introduction to the preventive medicine services.

Also, append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the office visit code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service. Link this E/M -25 code to the proper ICD-9 diagnosis for a separately identifiable problem.

For instance, suppose the 10-year-old boy in the above example is wheezing. For the preventive examination, the pediatrician still reports 99393 and V70.3. For the examination that is focused on the wheezing, the pediatrician reports the appropriate-level office visit (99211-99215, Established patient office visit) based on the time and work involved on that portion of the examination only. Modifier -25 is appended to the sick visit to indicate a significant, separately identifiable E/M service. Link the office visit to the reported symptoms, 786.07 (Wheezing)

For more on billing combination well visits and sick visits, see the May 2002 issue of the Pediatric Coding Alert.

If the child had a well visit in the past year and the insurance will not allow a second annual exam, report either the consultation or office evaluation and management, as appropriate. If neither code applies, file the well visit with a letter explaining the reason another checkup was required. The payer may refuse coverage, and you should inform the parent of this.