Pediatric Coding Alert

Question: Where can I find the official guidelines on when to use V20.2 versus V70.3? Should I use age 10 or age 12?Indiana SubscriberAnswer: Code V70.3 (Other general medical examination for administrative purposes) is not age restricted. Use this diagnosis for a general medical exam for adoption, camp, school, or sports that does not meet the requirements for a preventive medicine service (99381-99397). If you are referring to when to switch to V70.0 (Routine general medical examination at a health care facility) from V20.2 (Routine infant or child health check), although no ICD-9 guidelines officially delineate the age cut off, the American Academy of Pediatrics (AAP) and Medicare indicate the typical cutoff is 18. The AAP Bright Futures "Coding for Preventive Care" fact sheet (available at www.brightfutures.aap.org/clinical_practice.html) suggests switching to V70.0 at age 18 with 99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... 18-39 years). The Medicare Outpatient Code Editor (OCE) considers V20.2 a "pediatric age 0-17 diagnosis" as indicated by the yellow "P" that appears next to the ICD-9 code. The OCE detects inconsistencies between the patient's age and diagnosis, according to "Additional Conventions," Physician ICD-9-CM 2009, Volumes 1 and 2, page 6. If an insurer implements the age edit, the system would kick out 99385 (Initial comprehensive preventive medicine evaluation and management ... 18-39 years) or 99395 with V20.2. For 99381-99384 (New patient preventive medicine service infant through 17 years) and 99391-99394 (Established patient preventive medicine service infant through 17 years), payers who use OCE would require V20.2 indicating the patient's age is between 0-17 years.Best bet: To avoid rejections, be sure to check with your major payers. For instance, Indiana Medicaid in its carrier's presentation "Anthem 'Serving Hoosier Healthwise': State Sponsored Business" lists "Billing codes for Initial Health Assessments:• V20.2 for children (newborn to 18 years of age)• V70.0 for adults (19 years of age and older)."On the other hand, Harvard Pilgrim Health Care (Massachusetts, New Hampshire, Maine) in its "Payment Policies: Coding Overview" indicates to use V20.2 for "General pediatric examination (patients under age 18)."