Pediatric Coding Alert

By A.D. Jacobson, MD, FAAP

This months columnist, A.D. Jacobson, MD, FAAP, is chairman of the American Academy of Pediatrics (AAP) section on administration and practice management and a full-time pediatrician as well as a coding expert. He served on the AAPs coding and reimbursement committee, and is past editor of the AAPs Coding for Pediatrics. He practices with Pediatric Associates, a four-pediatrician practice in Phoenix, Ariz.

Without the code, theres no reimbursement. Thats why pediatricians need to be conversant with CPT. But they also need to think creatively because not all scenarios immediately fall within the strictures of CPT. There are so many factors that go into real-life situations with which the language of CPT may not seem to jive. But it doesits just a matter of getting to know the lingo. In the coding tips below, I have included some examples that may help illustrate the gray areas.

1. Prenatal counseling service. This is an area that many pediatricians become confused about when it comes to coding. Sometimes, the only option seems to be to provide the service for free and to consider it a marketing tool. But there are ways to bill for this service. First, you can use the counseling and risk factor reduction codes (99401-99404). Secondly, you can use the confirmatory consultation codes (99271-99275). For these codes, you do not need a referral from a provider. The patient can self-refer based on what her obstetrician has told her. Finally, you can use the consultation codes (99241-99245) if the obstetrician has referred the woman to you for prenatal counseling. Often, the diagnosis is of an intrauterine condition, and the obstetrician wants the mother to talk to you. You should bill the appropriate diagnosis code to the mothers insurance because there is no child yet. For other prenatal visits, such as with moms who want to talk about circumcision, breast-feeding or other general issues, the style of our practice is that we do not bill. We regard these visits as good public relations and marketing.

2. Time. Dont forget that time can be used as a factor in choosing the level of evaluation and management (E/M) service if counseling and/or coordination of care account for more than 50 percent of the face-to-face time with the patient. Pediatricians should enter the total duration of counseling and/or coordination of care into the clinical notes, as well as a description of the counseling and/or coordination of care taking place.

For example, a 2-year-old child comes into the office for a sick visit and is diagnosed with otitis media. The history and physical and decision-making would qualify for a CPT 99213 . The mother, however, requests counseling from the physician because of an upcoming divorce and current marital problems and the effect this situation is having on her children. A total of 10 minutes was spent on the history and physical and decision-making for otitis media, and 15 minutes was spent on counseling. A total of 25 minutes was spent during the visit. This therefore would qualify for a 99214 on the basis of time. It is important to use the ICD-9 code not only for otitis media but also for family disruption (V61.0).

3. Consultation codes (99241-99245). You can use these for your own patients. Examples include:
(1) request for a consultation from school for attention deficit/hyperactivity disorder (ADHD);
(2) request for a consultation from an emergency room physician asking you to see a patient; and
(3) request from a neonatologist asking you to see a premature newborn before discharge from the hospital.

4. Care plan oversight (99374 for 15-29 minutes, 99375 for 30 minutes or more). For many situations in which the pediatrician is ordering home therapy or coordinating other kinds of home care, the care plan oversight codes can be used. These codes are for a 30-day period and may be used for management of conditions such as jaundice when you have prescribed home photo therapy, or for use the first month after discharge from the hospital (for example, when a newborn is home on oxygen and requires a visiting nurse plan).

5. Dont undercode. CPT code 99214 should be used more often than it is. Most pediatricians underestimate their services. There are a number of encounters that very easily lend themselves to 99214. Examples include headache, abdominal pain, asthma (especially status), multiple problems and chronic disease with an acute process (such as a spina bifida [741.xx] patient with fever).

6. Always include chronic condition diagnosis code. To be able to justify higher levels of office visits, use a chronic condition diagnosis when an acute problem is presented, as well as the acute diagnosis. Examples of this include the chronic conditions of Downs syndrome (758.0) or diabetes mellitus (250.03). Always using the chronic condition diagnosis helps document the complexity of the decision-making process and ensures proper use of higher CPT codes.

7. Code for telephone calls and ask patients to pay. Although telephone calls (99371-99373) are seldom paid by insurance companies, pediatricians should code these when properly documented for a variety of telephone calls, which do take time. Many parents will agree to pay if the insurance company does not reimburse, providing that you schedule the telephone call ahead of time. This saves the patient the time and effort of coming in to the office.

8. Dont give up on modifier -25. Modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) should be used on the sick visit CPT code when a problem is discovered during a preventive medical services visit. It also should be used when there is an office visit and a procedure, such as cerumen removal (69210). If you have a hard time getting paid for an office visit and cerumen removal, remember to use the proper ICD-9 code for impacted cerumen (380.4). You must use different diagnosis codes; for example, you would use otitis media on the office visit and impacted cerumen on the procedure.

Note: For more on modifier -25, see article Get Reimbursed for Well Visit and Office Visit With Modifier
-25, on page 41 of this issue.

9. Use after-hours codes if you stay late. These codes (99050 for after hours, 99052 for 10 p.m to 8 a.m., and 99054 for Sundays and holidays) can be used if a patient is seen outside of your posted office hours. If your office closes at 6:00 p.m. and you see patients until 7:00 p.m., all such patients can have an after-hours code added to each encounter.

10. Scalp and head laceration coding. You should charge laceration repair in addition to an office visit for these encounters. CPT lists the proper code for laceration repair of head and scalp, depending on size of the laceration. The office-visit code (most commonly 99213 in this case) may require a -25 modifier, as well as an add-on code for an emergency office visit (99058).
For example, a 3-year-old patient is seen in the office after having a head injury on the playground. The physical examination demonstrates a laceration that will need superficial suturing (12001*). The patient is seen in the office on an emergency basis (99058). The physician documents physical examination, with emphasis on neurological examination to look for focal findings from the head injury. The office visit should be coded a
99213-25.