Pediatric Coding Alert

In the October issue of PCA (pages 79-80), we discussed the problem of coding for pre-operative examinations. The main problem is that HMOs, while they do cover well-visits, limit those visits (except for infants) to one a year, or one every two years. How can you get reimbursed for doing a pre-op exam if you have already given the patient the one allowed physical for the allotted time period? The answer, our sources said, is to use sick-visit codes. They recommended the low and mid-level codes99212 or 99213, and sometimes 99214.

Perhaps we were being too cautious. ,b>Harry J. Wander, MD, FAAP, chief of pediatrics for Sutter North Medical Group, an eight-pediatrician, one-physician assistant department in an 81-provider multi-specialty group, says that 99214 or CPT 99215 the highest level sick-visit codes should be used.

Using 99214 or 99215 for these exams seems appropriate and justified, writes Wander in a letter to PCA. A pre-op exam should be a comprehensive history and examination, not just a heart/lung check. The physician has to do a history of past illnesses and operations (in case there is any impact on the current procedure); check immunization growth and development status (to comply with JCAHO rules); check family history for bleeding tendencies and anesthesia problems; do a systemic review for intercurrent illness symptoms and the presence of other problems which should be surgically addressed at the same time, and then do a complete physical, not only to check the heart and lungs, [but also to check] for the presence of any other problems. Sometimes other problems are discovered, such as hernias or glue ears, which could be managed during the same hospitalization/anesthesia episode.

Documentation Issues

Since you will be dictating the examination to the hospital or surgical center as a history and physical, there should not be a problem with the documentation that would be required to justify the use of these higher codes, says Wander.

You also need to list your diagnosis codes in the proper order. The surgical diagnosis ICD-9 code should be listed first, he explains. The major medical problem diagnosis (if any) is listed next. Then, the diagnosis code V72.84 (preoperative examination, unspecified) should be listed; since it is a comprehensive exam, not just a cardiac or respiratory exam.

Finally, you can also use the consultation codes: 99244 or 99245 for outpatient surgery, and 99254 or 99255 for inpatient surgery. However, as noted in the October issue, many insurance carriers wont pay consultation codes in this situation.

Tip: Remember that a consultation has three elements: (1) a request from another physician for your opinion, evaluation, and advice; (2) you must see the patient; and (3) you must send a written response to the requesting physician.

We have had very few rejections or problems using consultation codes, says Wander.