Pediatric Coding Alert

With media coverage of school shootings and violence among children increasing, pediatricians are being called upon more frequently to counsel patients and their families about anger management, violent behavior and guns. These time-intensive visits can be coded in one of six ways.

Choosing a Code

1. Office visit (99212-99215, 99201-99205): If a parent brings a child to the office because of concerns about behavior the teen-ager may be sullen, listening to music with violent lyrics, dressing in gang clothing, performing poorly in school or exhibiting other signs that worry the parent code the visit based on time (99212-99215 for an established patient, 99201-99205 for a new patient). Although you may perform an extensive physical exam and history of present illness, counseling typically predominates.

Base the level on the time indicators in CPT: CPT 99201 (10 minutes), 99202 (20 minutes) 99203 (30 minutes), 99204 (45 minutes), 99205 (60 minutes), 99212 (10
minutes), 99213 (15 minutes), 99214 (25 minutes) and 99215 (40 minutes).

2. Consultation (99241-99245): If another source, such as a school nurse, requests that you see the child for violent behavior, you can bill an office consultation code (99241-99245), says Richard Tuck, MD, FAAP, founding chair of the AAP coding and reimbursement committee. Consultation codes are for new or established patients, and a physician may bill a consultation on his or her own patient.

As with the office visit codes, choose the level based on time, as more than 50 percent of the visit will be spent on counseling. The time indicators in CPT call for 15 minutes for 99241, 30 minutes for 99242, 40 minutes for 99243, 60 minutes for 99244 and 80 minutes for 99245. CPT allots more time per level to consultations than to office visits because consultations include higher relative value units.

Note: You must give a written report to the requesting source physician or school nurse to bill a consultation. For more information on billing consults, see Pediatric Coding Alert, April 2001, page 27.

3. Confirmatory consultation (99271-99275): A consultation does not have to come from a physician, but some payers prefer that it does. If the referral for the visit does not come from a physician, some coders believe confirmatory consultation codes (99271-99275) are more likely to be paid than the consultation codes. If a school thinks theres a problem, for instance, and they refer the child to you, you should use the confirmatory consultation codes, says Donelle Holle, RN, manager of professional fee services for the department of pediatrics, University of Michigan Health System, in Ann Arbor.

One good reason not to bill the confirmatory consultation codes is that CPT has not established times for them. You must choose a level based on all three elements of history, exam and medical decision-making. Even if you spend an hour on counseling, you cant use it in selecting a level.

In addition, confirmatory consultation codes are not for providing treatment, Tuck says. Use them when you offer your opinion and advice only. They would not be appropriate, he believes, when the referral comes from a school nurse and the pediatrician provides the care.

As Holle notes, however, Something is better than nothing. If your payers will not pay for a nurse-requested consultation, you may have to resort to her tactic of billing confirmatory consultations for such requests.

4. Preventive medicine services (99381-99385, 99391-99395): According to the American Academy of Pediatrics, all pediatricians should ask parents of young children whether there are guns and bullets in the house, and make sure the child doesnt have access to them. Known as anticipatory guidance, this aspect of preventive care is essential to the preventive medicine services codes (99381-99385, new patient; 99391-99395, established patient).

For older children, anticipatory guidance means talking to the teen about school, social life, dealing with anger and other issues.

The preventive medicine services codes pay well, but many health plans do not cover more than one visit every two or three years for adolescents. Therefore you must explore possible emotional problems when you do see the child. If you saw a child for a well visit in July, and again for behavioral problems in November, you will not be able to bill another well visit to the health plan.

5. Counseling codes (99401-99404): A pediatrician may also choose to access the counseling codes (99401 for a 15-minute session, 99402 for a 30-minute session, 99403 for 45 minutes, and 99404 for 60 minutes). These codes are to be used for the purpose of promoting health and preventing illness or injury, according to CPT. If the pediatrician wishes to conduct sessions to prevent violence with one or more teen patients who do not have signs or symptoms of violent behavior truly preventive sessions these codes are a good choice.

Counseling codes are for a separate visit and should not be combined with another E/M service. Not all payers cover these codes, however, so check with your representative before filing.

6. Prolonged services (+99354, +99355): Use prolonged services when you spend extensive time with a youth and parents. Prolonged services are add-on codes, to be used in addition to another E/M service, and never independently.

For example, parents bring in a 15-year-old who has been having a truancy problem and exhibiting violent behavior with his family and peers. The pediatrician spends 30 minutes taking a history and learns there is a pattern of school failure, drug and alcohol use, unprotected sexual activity, inappropriate handling of emotions and depression. He or she also spends 15 minutes on a complete physical exam and another 40 minutes talking to the parents with the child present and to the parents separately. Such a session could be coded with an office visit 99214 or 99215 and +99354, Tuck says.

Selecting an Appropriate ICD-9

Choose a primary diagnosis code based on the ICD-9 diagnosis that most closely matches your findings after the encounter. That may well be a mental diagnosis, which could result in nonpayment depending on the health plan policy and your contract (some payers carve out the behavioral diagnosis codes, allowing only a mental-health provider on their panel to bill them).

If you have signed a contract with a payer that does not allow you to use any of the mental disorders ICD-9 diagnoses (290.x-319), you can plead with the plan for an exception. Appropriate diagnoses for a violence-prone teen include anxiety states (300.xx), personality disorders (301.xx), adjustment reaction (309.xx) especially with predominant disturbance of conduct (309.3), disturbance of conduct (312.xx) and disturbance of emotions specific to childhood and adolescence (313.xx).

You may find that payers recognize the mental disorders diagnosis codes, but pay only partially for them. Our insurance companies reimburse at 50 percent if the mental disorders codes are used, Holle says. Therefore, if you normally receive $130 for 99214, and you bill it with 309.1 (prolonged depressive reaction), the payers will reimburse only $65. To offset the reduction, you may collect the remaining portion from the parent.

If the contract with the payer specifically excludes treatment for mental disorders, including counseling, you can bill the parents, Tuck says. Your coding must still be accurate, however. Never falsify a diagnosis code just to get paid. Read your contracts before signing them and, if necessary, call the medical director and discuss the importance of counseling teens before violence erupts.