Pediatric Coding Alert
Opt for E/M Code Instead of Med Management
Pennsylvania Subscriber
Answer: CPT permits any physician to bill any procedural code, including 90862 (Pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy). But payers may implement software system edits that permit only psychiatrists to use psychiatric codes, such as the medication management code. You may also receive 90862 denials due to payers' mental-health carve outs. These policies treat mental-health services as noncovered benefits when a primary-care physician provides them.
A mental-health carveout recognizes that a payer already has a paid contract with a mental-health provider organization, such as Magellan, to provide all their mental-health services. Therefore, they consider paying a primary-care physician for providing those services as an additional and duplicative cost to their plan.
You should instead consider coding the follow-up visits as E/M services. Often, these encounters involve a history, examination and medical decision-making and thus qualify as 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient ...). Tip: If counseling and/or coordination of care comprises the majority of the visit, you may use time as the key component when assigning the E/M service level.
Best practice: Reserve 90862 for medication management visits in which you provide no psychotherapy and no E/M component. If the pediatrician performs these services, you can include the management in the E/M service, according to CPT Assistant Summer 1992.
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