Pediatric Coding Alert

Are difficult children or worried parents consuming your valuable time? When counseling consumes more than 50 percent of an office visit, you can recoup your work by coding the visit based on time.

Master the Requirements and Time Frames

Because the pediatrician must examine a new patient before billing for counseling, the new patient E/M codes require all three elements:

1. history
2. examination
3. medical decision-making.

Established patients require only two of the elements. Therefore, the patient (child) does not need to be present for a valid established patient E/M encounter:

1. history
2. medical decision-making.

For an established patient office visit, CPT Codes recommends the following time allocations:
 

The time parameters for new patient office visits vary slightly:
 

For an established patient, if the pediatrician spends five minutes with the parent and child and 10 minutes with the child, for a total of 15 minutes, you should report 99213 (Office or outpatient visit for the evaluation and management of an established patient, which requires at least two of these three components: an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity physicians typically spend 15 minutes face-to-face with the patient and/or family).
 

Parents,Guardians Qualify for Time Criteria

Sometimes, a pediatrician needs to spend more time with the parents than with the child. For example, the parents may not discipline effectively or may have inappropriate expectations. The pediatrician deserves reimbursement for educating and counseling parents by billing the E/M code, says Richard H. Tuck, MD, FAAP, member of the American Academy of Pediatrics national committee on coding and nomenclature.

CPT allows the use of E/M codes for counseling an established patient's parent, Tuck says. When counseling consumes more than 50 percent of "the physician/patient and/or family encounter," the physician can use time as the key factor in selecting a level of E/M code, according to CPT's E/M services introduction. If the person is legally responsible for the patient's care, even if he or she is not a family member, e.g., "foster parents, person acting in locum parentis, legal guardian," you can bill for the time, CPT Assistant November 1999 explains.

Beware of Diagnosis Pitfalls

When selecting a diagnosis for the counseling, you should consider three issues:

1. The payer might not pay for a 300-series code, e.g., 300.9 (Neurotic disorders; unspecified neurotic disorder), 305.20 (Nondependent abuse of drugs; cannabis abuse; unspecified) and 309.0 (Adjustment reaction; brief depressive reaction), if they have a mental-health carve-out or mental-health services, unless the pediatrician is a listed mental-health provider with the plan.

2. The payer might not recognize V codes, e.g., V40.0 (Mental and behavioral problems; problems with learning), V40.3 (... other behavioral problems) and V65.1 (Other persons seeking consultation without complaint or sickness; person consulting on behavior of another person).

3. The pediatrician might not want to "label" a child with one of these diagnoses. In those cases, bill the parent directly, says Susan Callaway, CPC, CCS-P, an independent coding auditor and trainer in North Augusta, S.C.

Know ahead of time which diagnosis codes the patient's plan covers, Callaway recommends. If the plan won't pay, you must warn the parents that they may be responsible for the bill, she says. Most parents will gladly pay you for your assistance.