Pediatric Coding Alert

Let condition, coverage steer selection.

Before you write off time you spend providing smoking cessation or awareness counseling, see if you're exercising all eligible coding alternatives with this quick quiz.

Reserve 99401-4 for Extensive Vaccine Counseling

Scenario 1: A pediatrician provides a new-patient well check to a 2-month-old and explains the importance of vaccinations to the mother who expresses concerns about thimiserol and autism and questions their relationship to immunizations. The physician spends 15 minutes explaining the studies showing no links between autism and vaccinations, as well as the elimination of thimesorol from vaccines. He also stresses the importance of disease prevention through high levels of population vaccination and points out the state's school entrance requirements do not allow unvaccinated children to enroll. The mother still refuses to vaccinate the infant. How can the physician recoup the time he spends on this vaccination counseling that is beyond the typical vaccination counseling included in the preventive medicine service?

Answer 1: You can use 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes) in addition to 99381, appending the 99401 with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service). "This is what we recommend for pediatricians who spend an extensive amount of time counseling parents at well-child visits on vaccines and vaccine safety," says Becky Dolan (Marco), MPH, CPC, health policy analyst for the Division of Health Care Finance and Quality Improvement at the American Academy of Pediatrics in Elk Grove Village, Ill. The time spent in the additional vaccine safety counseling needs to be clearly documented in the chart notes.

CPT 2008 removed the restriction on reporting preventive medicine counseling codes with another E/M code. Therefore, you do not have to report the preventive medicine counseling codes at a separate encounter. Reserve 99401-99404 for counseling/risk factor reduction not typically provided with a preventive medicine visit.

You would link 99401 to the parent refusal for vaccination (V64.02), and 99381-25 to V20.2 (Routine infant or child health check), says Charles Scott, MD, FAAP, pediatrician at Medford Pediatrics and Adolescents in New Jersey.

You'll always use 99401-99404 with a V code, not a condition code. The preventive medicine counseling codes are for patients who do not have a current diagnosis or condition for which they are receiving the counseling.
 
Try 99406-7 When Teen Is Dipping

Scenario 2: During a 15-year-old male's periodic preventive medicine service, the pediatrician discovers the adolescent is dipping tobacco on a regular basis. The pediatrician spends 10 minutes counseling the patient on the risks involved in using dip and motivates the patient to stop the behavior. Should you include the tobacco use cessation in the preventive medicine service?

Answer 2: No, you can code the problem separately. For the 10 minutes of tobacco cessation counseling, use 99406 (Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes) and 305.1 (Tobacco use disorder). Also, report 99394-25 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... adolescent [age 12 through 17 years]) linked to V20.2.

Use E/M-25 If Payer Denies 9940x

Scenario 3: I have been reporting preventive medicine counseling, smoking/tobacco use cessation, and substance behavior intervention, but insurers are not covering the codes. Can I charge the patient for the discussions?

Answer 3: While you can, there's a better alternative. For insurers that don't pay for the preventive medicine and behavior change, coding the office visit based on time spent counseling may be more pragmatic, Scott suggests.

Here's how: For seven and a half to 12 and a half minutes spent on counseling/interventions using CPT's closest time rule, you could report 99212-25 (Office or other outpatient visit for the evaluation and management of a patient ... physicians typically spend 10 minutes face-to-face with the patient and/or family) just like you would for any other significant and separate problem that you address at a preventive medicine service.

Documentation should include the total time of the face-to-face problem portion, as well as the time spent on counseling and a summary of the discussion. For instance, a note could indicate 10 total time (T)/10 counseling (C): "Explained dipping can lead to deterioration, cancer of teeth, gums; suggested chewing sugar-free gum."

Catch this: Code 99212 contains 0.68 more relative value units on the 2008 Medicare Physician Fee Schedule than 99406.