Pediatric Coding Alert

Question: A pediatrician sees new patient twins for their four-month well visit. Chart shows patients have history of preterm (31 weekers) and one baby was on CPAP for a few days. The physician finds the patients have decreased tone during exam; the pediatrician refers them to a pediatric ophthalmologist. The pediatrician has to review past records, and wants to bill more than new patient well visits due to the time she spent reviewing records and discussing history. Do the new patient codes include that extra time? Can I add extended services?

Oklahoma Subscriber

Answer: If the pediatrician documented the additional indirect time, you can use +99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care [e.g., review of extensive records and tests; communication with other professionals and/or the patient/family]; first hour ...) and possibly +99359 (... each additional 30 minutes ...) in addition to 99381 (Initial comprehensive preventive medicine evaluation and management of an individual ... infant [age younger than 1 year]). You cannot, however, bill for direct prolonged service. You can use these only with time-based codes.

Many insurers do not pay for indirect prolonged services. Instead consider capturing the problem portion of the encounter, the direct prolonged service time and possibly the indirect time, with a new patient sick visit code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient ...). CPT clarified in October 2006 CPT Assistant's Q&A: "Evaluation and Management" that you should code a new patient as new throughout the initial patient-physician encounter, meaning you should use 99201-99205 (Office or other outpatient services; new patient) with 99381-99385 (Preventive medicine services; new patient, not 99212-99215 (Office or other outpatient services; established patient).

To indicate the problem portion is significant and separate from the preventive medicine service, attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of a procedure or other service) to 99201-99205. You may have to appeal for the problem portion payment but some commercial carriers pay both services.

Using separate ICD-9 codes to support each portion of the encounter will help support billing the office visit. Report the office visit with the baby's gestational period (765.26, Disorders relating to short gestation and low birthweight; weeks of gestation; 31-32 completed weeks of gestation) and current problems (such as hypotonia, 359.0). For the preventive medicine service, use the infant health check diagnosis (V20.2, Health supervision of infant or child; routine infant or child health check).