Pediatric Coding Alert

Question: Achild presents with a high lead toxicity level. The pediatrician counsels the parents regarding what they should change in their house, the babysitter's house, and the grandparents'house, as well as what they need to look for in the paint. The pediatrician spends 30 minutes establishing the diagnosis and 45 minutes counseling the parents. Should I report 99213-25 and 99402?

Iowa Subscriber

Answer: Because the child has an established illness, you shouldn't use 99402 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 30 minutes). When your pediatrician provides counseling at a separate visit for a patient who doesn't have any symptoms or an illness, you may submit counseling and/or risk factor reduction intervention.

To capture this encounter's counseling time, you should instead include the 45 counseling minutes in the E/M service. Because counseling dominates the visit, it qualifies for time-based billing.

If you add the 30 face-to-face diagnosis minutes to the 45 counseling minutes, you get 75 reportable minutes. Submit the first 40 minutes with 99215 (Office or other outpatient visit for the evaluation and management of an established patient ... physicians typically spend 40 minutes face-to-face with the patient and/or family). Capture the additional 30 minutes beyond the usual time CPT designates for 99215 (40 minutes) with +99354 (Prolonged physician service in the office or other outpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., prolonged care and treatment of an acute asthmatic patient in an outpatient setting]; first hour [list separately in addition to code for office or other outpatient evaluation and management service]).