Pediatric Coding Alert

Question: A cystic fibrosis patient and her mother met with our pediatrician to discuss her need for a power wheelchair. Although the patient has trouble breathing after climbing stairs, she denied any types of musculoskeletal problems or weakness, and had no chief complaint because the pediatrician had just seen her a week ago to examine her completely and answer all of her questions. After the examination, the doctor determined there was no need for the patient to have a power wheelchair at this time. In fact, the child seemed like she didn’t want or need one and the mother was pushing for it. We billed 99213 with diagnosis V70.5, but the payer denied the claim as “routine.” Should we have billed the visit as preventative?

Colorado Subscriber

Answer: Depending on how much time the physician spent with the patient and how much of the visit was spent counseling/coordinating care, you should be able to report the encounter with 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) or 99214 based on time spent with the patient and her mother discussing the patient’s condition and the factors involved with the decision on whether to prescribe the wheelchair. You would report the diagnosis as 277.02 (Cystic fibrosis with pulmonary manifestations), and the chief complaint should be what the mother cited, which was trouble breathing after climbing stairs. The decision-making involved is in determining whether the patient needs a power wheelchair related to the shortness of breath.

You won’t want to bill the visit as preventive because it does not meet the guidelines and content of a visit supporting a preventive medicine code.

Consider: If your physician did not document the requirements to bill an office visit code such as 99213 (e.g., he didn’t document time spent or time counseling/coordinating care and didn’t document an exam or history), another option could be the preventive medicine counseling codes (99401-99404, Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure] …), since this visit is about having the conversation regarding whether or not the patient needs a power wheelchair as a risk factor reduction (to avoid falls when tired, conserve energy from walking or climbing stairs, etc.). In this case, you may also want to use a diagnosis from the V65.4x (Other persons seeking consultation; other counseling, not elsewhere classified). Viable options might include V65.43 (Counseling on injury prevention) or V65.49 (Other specified counseling) to reflect the counseling nature of the encounter instead of V70.5 (Health examination of defined subpopulations), which is exam focused and doesn’t necessarily apply to this situation. The payer may deny the encounter, but the CPT and ICD-9 codes will better sync up and reflect the nature of the encounter if you follow this logic in your coding.