Pediatric Coding Alert

Double your education reimbursement with assessment/intervention codes

You can boost reimbursement for nonphysician-provided asthma and diabetes education if you take advantage of the health and behavior assessment/ intervention codes, 96150-96155.

Assigning 96150 instead of CPT 99211 could net you about $30 more for a 30-minute counseling session. A nurse often performs these services, but any nonphysician staff, such as a medical technician, may perform these duties.

Watch out: A pediatrician or nonphysician practitioner (NPP), such as a nurse practitioner, cannot use these codes, but should instead use the appropriate-level E/M code

Learn how to report the underused 96150-96155 series in the following case study.

Nurse Has More Options Than 99211

A nurse provides asthma education and defers prescriptions and medication questions to the supervising physician. "Because this is not a group setting, and a nurse provides the services, the encounter doesn't qualify as 99078 (Physician educational services rendered to patients in a group setting)," says Jamie Kurrasch, CPC, coding specialist at Primary Care Partners in Grand Junction, Colo. A qualified nurse performs the services. You also can't report an E/M code other than 99211, because they all require a physician or nonphysician practitioner.

Although 99078 and 99201-99204/99212-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient ...) don't apply to nurse services, 99211 isn't Kurrasch's only option. "This is the perfect time to use the health and behavior assessment/intervention codes," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

Why: A nonphysician provides the services, and the patient has an established illness. "Practices can really get nurses involved with special-needs patients who require more counseling/intervention time," Tuck says.

Patient Must Have an Established Diagnosis

The health and behavior assessment codes can come in handy for asthma education, as well as diabetes (such as 250.01, Diabetes mellitus without mention of complication; type I [juvenile type], not stated as uncontrolled). Typically, health and behavior assessment and intervention services address an assortment of physical health issues - including patient adherence to medical treatment, symptom management, health-promoting behaviors, health-related risk-taking behaviors, and overall adjustment to physical illness.

Caution: Don't use 96150-96155 for attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD) counseling. "The health and behavior assessment/intervention codes identify and address psychological, behavioral, emotional, cognitive and social factors to prevent, treat or manage acute or chronic physical health problems," Tuck says. Codes 96150-96155, however, do not describe treatment of a diagnose that ICD-9 categorizes as a mental-health disorder, such as 314.00 (Attention deficit disorder; without mention of hyperactivity) or 314.01 (... with hyperactivity).

Codes Describe Various 15-Minute Sessions

You can, however, use these codes in a variety of situations. For instance, the health and behavior assessment/intervention codes come in handy when a patient benefits from group therapy (96153, Health and behavior intervention, each 15 minutes, face-to-face; group [2 or more patients]) or family therapy (96154, ... family [with the patient present]; or 96155, ... family [without the patient present]).

Key: All of the codes represent 15-minute increments of counseling. You should report one unit of the appropriate code per 15 minutes.

Suppose the nurse in the case study spends 30 minutes on asthma education. She performs an initial assessment of the life-style issues that contribute to a child's frequent extrinsic asthma attacks and discusses ways that the child can reduce environmental exposures. She reviews medication compliance.

The intervention is for an individual's initial assessment, so you should use 96150 (Health and behavior assessment [e.g., health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires], each 15 minutes face-to-face with the patient; initial assessment) with 493.01 (Extrinsic asthma; with status asthmaticus). To account for 30 minutes of assessment, assign 96150 x 2 units.

Comparison: If you instead report the encounter as 99211, you reduce your potential reimbursement for the services by $30. Code 99211 pays about $21.60 based on the 2005 National Physician Fee Schedule, which assigns a nurse visit 0.57 relative value units (RVUs). In contrast, the Fee Schedule reimburses 96150 at $26.15 per unit, or 0.69 RVUs.

The improved reimbursement results when you bill counseling sessions using multiple units of 96150 ($26.15 x 2 = $52.30) instead of 99211's flat rate ($21.60). And the good news is that "insurers are reimbursing the health and behavior assessment/intervention codes," Tuck says.