Pediatric Coding Alert

Question: Some of our patients have chronic conditions that consume a lot of the pediatrician's time, especially on the telephone. How can we be reimbursed for these services? Also, if a child has a chronic condition, should we always list that diagnosis at every visit, even a diagnosis that is unrelated to the chronic condition?

North Carolina Subscriber

Answer: Use esoteric codes care plan oversight and telephone codes to get ethically and adequately reimbursed for the extra time and work involved with these patients. Payers may accept them if they understand the medical necessity.

Case management is a major consideration for these patients. The physician must spend a lot of time on the telephone to coordinate care with other providers. Telephone codes (99371-99373) can be used for discussing the case with the patient, parent or other providers.

Care plan oversight services codes can be used when the physician supervises a patient under the care of a home health agency (99374-99375), a hospice (99377-99378), or a nursing facility (99379-99380).

Coding is usually high-level when a patient is newly diagnosed with a chronic condition, but coding falls as the condition is controlled, with spikes of higher-level codes as problems occur.

The first visit at which a patient is diagnosed with migraine headaches (346.xx), for example, will involve lengthy counseling with the parent. Code for the visit based on time: This will probably be a 99215. At the second visit, when the pediatrician assesses the treatment's effectiveness, the E/M service will likely be somewhat lower. Long-term follow-up visits will probably decrease to level two or three.

You should include the diagnosis code for the chronic condition in addition to the acute diagnosis at each visit because it demonstrates the need for a higher level of medical decision-making even for an earache or a cold. Some examples demonstrate how this works:

1. A well-controlled asthmatic comes for a well visit; if the asthma is relevant to the well visit, the asthma diagnosis (493.xx) should be listed as well as the well-visit diagnosis (V20.2, Routine infant or child health check).

2. A patient has a severe chronic condition such as spina bifida (741.xx, Spina bifida), leukemia (205.xx, Myeloid leukemia), or kidney cancer (189.x, Malignant neoplasm of kidney and other and unspecified urinary organs) and comes in with a cold. List the cold diagnosis (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site) and the chronic diagnosis.

3. A patient with a chronic condition has otitis media (381.xx). If the child also has leukemia with an altered white blood cell count, or is on chemotherapy for cancer, or has a shunt for spina bifida, list the earache diagnosis with the chronic diagnosis to show the medical decision-making was more involved than it would be with a healthy child.

Listing multiple diagnoses will also help explain frequent patient visits. If a pediatrician has seen a patient 20 times in the past year and all the diagnosis codes are for a minor laceration of a finger (883.0, Open wound of finger[s]; without mention of complication), urinary tract infection (599.0, Other disorders of urethra and urinary tract; urinary tract infection, site not specified) or otitis media, the insurer may think the pediatrician is seeing the child inappropriately. But if you add leukemia, they will understand why this child is seen for a cold. Furthermore, if your office is on an adjusted capitation program, the fee is higher for a patient with a chronic diagnosis.