Pediatric Coding Alert

Payer May Allow You to Destroy Depression Questionnaire

Question: In our pediatric practice we screen mothers for post-partum depression using the Edinburgh Postnatal depression questionnaire as per American Academy of Pediatrics guidelines. The proper code for this service is 99420. We document in the infant's chart that the questionnaire was reviewed, a positive or negative result, and any action taken. Do we need to file the actual questionnaire in the infant's chart in order to qualify for reimbursement for the service? We would prefer to shred the questionnaire for confidentiality reasons.

Minnesota subscriber

Answer: You may destroy the actual test provided the following information is included in the documentation, based on direction from the MinnesotaCare Web site (www.mnscha.org/pdfs/providers/manual/Chapter%2018%20Child%20and%20Teen%20CheckUp%20Programs.pdf):

"For service documentation purposes, record the name of the completed screening tool and that the screening was performed as a risk assessment in the child's medical record. You are not required to include the screening score, results or a copy of the screening tool in the child's record. You may give the mother a paper copy of the screening tool to bring with her to a referral appointment or destroy it if she does not want it."

Other insurers may follow different regulations for these documentation requirements, so check with individual payers. In general, for screening tools, documenting the tool, the screening results, and the physician discussion is sufficient.