Pediatric Coding Alert

Question: We provide early childhood intervention services and have 12 pediatricians who bill re-evaluation codes. Instead of using CPT 99347 for these services, may I report a standard E/M, such as 99213?

Texas Subscriber

Answer: CPT requires coding to the highest level of specificity. Therefore, reporting an office visit, such as 99213 (Office or other outpatient visit for the E/M of an established patient ), when that is not what your pediatrician performs is inappropriate. CPT provides a code for the home visit (99347, Home visit for the E/M of an established patient ), and you should use it.

In fact, billing 99213 instead of 99347 would cost your practice $12.15 per visit, based on the Medicare Physician Fee Schedule. (Although you probably don't file Medicare claims, many private payers use the fee schedule to determine their rates.) In addition, if a physician visits a patient in a private residence and documents why he or she cannot travel to the office, most insurers cover the service.

Perhaps you want to use 99213 because its components are more equivalent to the level of service that the doctors usually provide. Rather than resorting to the office visit code, you should report a higher-level home visit code, such as 99348, if documentation shows that the physician performs two of the three key components. For instance, if the pediatrician performs and documents an expanded problem-focused interval history and an expanded problem-focused examination, she should use 99348 instead of 99347.