Pediatric Coding Alert

Question: BlueCross National Capital Area (NCA) started applying claims containing V20.2 as other than Well Care. The insurer blames the denials on incorrect coding. The representative explained, "They know there is another code for Well Care, but they do not know what it is." Does ICD-9 include another diagnosis that I should use?

Maryland Subscriber

Answer: The insurer could want you to use the adult preventive service examination code V70.0 (General medical examination; routine general medical examination at a healthcare facility). Per CMS, 18 years is the usual cut-off age for the infant and child health check-up V code (V20.2, Health supervision of infant or child; routine infant or child health check).
 
Support: The Additional Conventions section of the AMA's ICD-9-CM Volumes 1 and 2 designates V20.2 as a pediatric diagnosis for ages 0-17. The "P" in the yellow square following V20.2 indicates "These diagnoses are intended for children, and the patient's age must [be] between 0 and 17 years," according to the Age and Sex Edit Symbols subsection on page 6. CMS uses the ages in its Outpatient Code Editor (OCE) to detect inconsistencies between the patient's age and diagnosis.
 
Implication: You should use V20.2 with infant (age under 1 year) through adolescent (age 12 through 17 years) preventive medicine service codes (99381-99384, Initial comprehensive preventive medicine evaluation and management of an individual ...; and 99391-99394, Periodic comprehensive preventive medicine re-evaluation and management of an individual ...).
 
Switch to V70.0 when a patient who is 18 or older presents for a well-check (99385-99387, New patient preventive medicine service; and 99395-99397, Established patient preventive medicine service).
 
Hitch: Private insurers may have different age guidelines. For instance, Mississippi Medicaid indicates that coders should use V20.2 until a beneficiary is 21 years old. Other payers want physicians to switch from V20.2 to V70.0 when a patient turns age 5.
 
Best bet: Ask your representative to send you a letter or e-mail stating at what age BlueCross NCA wants you to start using V70.0. Explain that Medicare considers V20.2 a pediatric code and that you'd be happy to comply with contradictory guidelines if he supplies you with an alternative written policy to follow. Written guidelines will support your billing policy and protect you in the event of an audit.