Pediatric Coding Alert

Question: A pediatrician and physician assistant are educating some parents on diabetes, exercise, and nutrition at our practice twice a month. The plan is to bring the patients in at 4:45 to workup the patient, and start the group session at 5 p.m. for about 45 minutes to an hour. Can practices report these services? Will carriers pay for them?

Answer: You have a few options depending on what insurers cover.

Option 1: Assuming that the workup involves an individual face-to-face evaluation of the patient, report the appropriate level E/M service, such as 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...). Use physician group education codes for the 45-minute counseling session.

Since the education is in a group setting provided by a physician or nonphysician practitioner (the physician assistant [PA]) and the patients have an established illness (diabetes), the sessions fall under 99078 (Physician educational services rendered to patients in a group setting [e.g., prenatal, obesity, or diabetic instructions]).

This code is not time-based and can be coded per patient. You can report the office visit appended with 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) in addition to the physician educational services.

Pitfall: Because the Medicare Physician Fee Schedule considers 99078 a bundled service and assigns it no relative value units (RVUs), Medicaid carriers and private payers may not pay for the educational services code. This could be the case even though it is a valid, specific service supported by CPT® and supported by the American Medical Association Resource-based Value Committee (RUC).