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Pediatric Coding Alert

Support Higher-Level Family Counseling Sessions Using 7 V Codes

Published on Fri Mar 13, 2009

This series helps show why $55 more for a 99214 could be in order.

Still don't have V61.0___ on your superbill? Your E/M levels could be suffering.

"Pediatricians frequently deal with dysfunctional families," and the family disruption series, V61.0x, helps support work done within these codes' described issues, says Richard Tuck, MD, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

Using a counseling diagnosis often supports a higher level of CPT coding for these time-dominated visits.

If you're sold on reporting family disruption diagnoses, get started here.

Discover 7 Disruption Types

"Going along with our times," ICD-9 2009 added codes for family disruption, explained Katie Arnold CPC, CPC-H, CPC-IM, in her update presentation at Dartmouth-Hitchcock Medical Center in Lebanon, N.H.

Effective Nov. 1, 2008, V61.0 was deleted and was expanded into seven codes for "family disruption due to...." For an encounter needed for a family member on military deployment, you can use V61.01. "You've got a code for disruption due to return of family member from military deployment (V61.02)," points out Arnold, who is manager of coding education and QA at DHMC. Other codes include disruption due to:

divorce or legal settlement V61.03 ... divorce or legal separation

parent and child estrangement V61.04 ... parent-child estrangement

welfare custody V61.05 ... child in welfare custody

foster care V61.06 ... in foster care or in care of

non-parental family member

other family disruption V61.09 ... family disruption, includes

"Family estrangement NOS"

Look for Counseling Session's Condition, Percent

"There's significant potential for using the family disruption codes in counseling sessions regarding divorce, foster care, military parent, etc." Tuck points out.

What CPT codes could you use for a family disruption counseling session? This "could be a counseling encounter (99401-99404, Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure] ...) or disruption (for example, an E/M level code)," says Rebecca Lopez, CPC, at Bright Health Physicians in Whittier, Calif.

Before using these codes, consider these requirements:

• 99401-99404: To use the preventive medicine service codes, the patient cannot have a specific illness that the counseling session might treat.

Example: A child's deployed parent is expected to return home. The pediatrician discusses possible issues, suggests reacclimation techniques, and identifies problem warning signs. For a session on preventing and reducing adjustment problems that lasts 10 minutes, you would code 99401 (... approximately 15 minutes) with V61.02.

• E/M level: "If the counseling and/or coordination of care dominates (more than 50 percent) the physician/ patient and/or family encounter (face-to-face in office or other outpatient settings), time can be the key or controlling factor to qualify for a particular level of E/M service," such as 99201-99215, (Office or Other Outpatient Services), Lopez notes. Documentation must include the encounter's total face-to-face time, counseling time, and a brief discussion summary.

Example: A mother asks a pediatrician to talk to her daughter about an impending divorce and to discuss the custodial arrangements. The physician spends 10 minutes gathering the history of the divorce and asking questions about the patient's health. He then spends 15 minutes counseling the parent and patient on her concerns, fears, and anger, and documents "spent 15 total minutes counseling on managing feelings during upcoming divorce and changed living arrangements." Total visit time is 25 minutes.

Based on the performed and documented history, examination, and medical decision making, the visit qualifies as a level-two established-patient office visit (99212, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ... Physicians typically spend 10 minutes face-to-face with the patient and/or family).

Because counseling comprised more than 50 percent of the encounter's total face-to-face time, you instead can select the E/M level using time as the controlling factor.

Money maker: Reporting V61.03 helps support the visit's higher level of 99214 (... a detailed history; a detailed examination; medical decision making of moderate complexity ... Physicians typically spend 25 minutes face-to-face with the patient and/or family), which equates to approximately $55.18 more in pay than 99212.

Medicare's 2009 Physician Fee Schedule, which can be used as a benchmark for private payers' rates, assigns 1.03 relative value units (RVUs) to 99212 and pays the code nationally at $37.15. Code 99214 has 2.56 RVUs and pays a national rate of $92.33.

Recognize Other V61.0x Encounters

You'll sell yourself short if you limit family disruption ICD-9 codes to counseling sessions. You might find V61.0__ beneficial when a patient seeks or receives medical advice or care due to family disruption. "If the physician uses an E/M code, there could be other diagnoses, such as stress (for instance, 308.3, Other acute reactions to stress) and/or depression (for example, 309.0, Adjustment reaction; adjustment disorder with depressed  mood)," Lopez relays.

Don't miss: You're free to couple V61.0__ with another ICD-9 code, as appropriate. CPT does not indicate that you should use category V61 as only a primary or secondary diagnosis, Lopez points out.

Example: A teenager who is in foster care has been having fatigue and weight loss. During an office visit, the pediatrician diagnoses her with depression caused by her prolonged stay in foster care. The physician assigns a level-four established-patient visit based on performed and documented key elements of history, examination, and medical decision making.

This type of visit could support 99215 (... a comprehensive history; a comprehensive examination; medical decision making of high complexity ... Physicians typically spend 40 minutes face-to-face with the patient and/or family) if the total visit is 40 minutes and total face-to-face time counseling on the diagnoses related to depression, foster care, and other diagnoses predominates. For the diagnoses, you submit fatigue 780.79 (Other malaise and fatigue), weight loss (783.21), depression (311), and V61.06.

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