Primary Care Coding Alert

If you-re not clear on the associated services you can code outside a preventive medicine service, you could overlook charging many ancillary services.

"The American Academy of Pediatrics recently issued new age-appropriate preventive medicine guidelines," says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. The Bright Futures Guidelines recommend evidence-based periodicity for history, measurements, sensory screenings, developmental/behavioral screenings and procedures.

Here's what you can capture in addition to the preventive medicine service code (99381-99385, New patient preventive medicine service; 99391-99395, Established patient preventive medicine service).

You take history and measurements at all preventive medicine services, except neonatal, "which are giveaways, pure and simple. The history and measurements are part of the preventive medicine code and cannot be billed separately," says Herschel R. Lessin, MD, vice president and clinical research director at The Children's Medical Group in Poughkeepsie, N.Y.

Exception: Your history uncovers a specific problem, Lessin says. In this case, you would need modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to bill a separately identified and documented E/M service (99201-99215, Office or other outpatient visit ...).

Heads up: The added body mass index (BMI) recommendation starting at age 2 means you may report an additional ICD-9 code. Use the BMI percentile to choose the correct V85.5x code. For instance, you would represent a 3-year-old girl's 10 percent BMI with V85.52 (Body Mass Index, pediatric, 5th percentile to less than 85th percentile for age).

Similarly, you would include the examination in the preventive medicine service.

CPT does not include ancillary services and screenings in the preventive medicine service codes. Therefore, you should separately report any vision or hearing screening.

Red flag: You should not, however, separately code the risk assessment, such as using informal questions to assess for vision or hearing problems that the guidelines recommend providing at preventive medicine services, in which screenings aren't indicated. If your risk assessment resulted in a positive, meaning the child required screening, you would then code the appropriate sensory screening code.

The guidelines break developmental assessment into two portions:

1. Surveillance, which "is a flexible, ongoing process where knowledgeable professionals perform skilled observations of children during the healthcare visit," according to the manual for Tennessee AAP's EPSDT (Early and Periodic, Screening, Diagnosis and Treatment). When you provide and document surveillance often through an age-appropriate checklist, include the work as part of the preventive medicine service.

2. Screening may arise from an age recommendation or from positive surveillance. If you use a standardized, validated tool, such as the Parent Evaluation of Developmental Status (PEDS) or Ages and Stages Questionnaire (ASQ), you should separately report the screening with 96110 (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) and V20.2 if the test is normal. You may also use ICD-9 codes, such as 315.31 (Expressive language disorder), for any findings related to a positive screening.

For autism screening, which the Bright Futures guidelines recommend at the 18- and 24-month visits (99382, - early childhood [age 1 through 4 years] or 99392), you-ll use the same developmental testing code (96110). Once again, to use the code, testing must involve a standardized, validated tool, such as the Australian Scale for Asperger's Syndrome or the Modified Checklist for Autism in Toddlers (M-CHAT).

Alternatives: The Pediatric Symptom Checklist (PSC) and PSC-17, an emotional/behavioral screen, also qualifies as 96110.

You won't use new-for-2008 codes 99408-99409 (Alcohol and/or substance [other than tobacco] abuse structured screening [e.g., AUDIT, DAST], and brief intervention [SBI] services -) to represent the alcohol and drug use assessments now recommended at ages 11-21. These codes require an intervention in addition to a screening. You-ll instead include a negative risk assessment in the preventive medicine service.

Of course, you should separately code for the bread and butter of your services -- immunizations. Make sure to report both the product (90476-90749) and its administration (90465-90474), unless you are billing Vaccines for Children (VFC). Because this program distributes the product for free, you are to charge only for the administration in those cases.

For private payers, identify each product's administration by linking the product's V code to the administration code as well. Some payers prefer and/or accept V20.2 for all administration codes.

Counseling changes coding: CPT has separate codes for vaccine administration with counseling. If the FP provides vaccine counseling and the child is younger than 8 years old, use 90465-90466 (percutaneous, intradermal, subcutaneous or intramuscular) or 90467-90468 (intranasal or oral) with V03.81-V06.8. For children age 8 and older and/or for administration without physician counseling, report 90471-90472 or 90473-90474, depending on the delivery method, linked to V03.81-V06.8.

If you have a certificate of Clinical Laboratory Improvement Amendments (CLIA) waived status, you may conduct some preventive medicine service-related tests in your office.

These include

- hemoglobin testing (85018, Blood count; hemoglobin [Hgb]), which is recommended at the 12-month preventive medicine service (99382, 99392)

- dipstick urinalysis (81002, Urinalysis, by dipstick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, without microscopy), which the guidelines no longer require at any age

- lipid panel (80061) for dyslipidemia (cardiovascular) screening, preferred at the 20-year visit (99385, - 18-39 years; or 99395 linked to V70.0, General medical examination; routine general medical examination at a healthcare facility).

You may separately report performing these tests. Some insurers may want HCPCS modifier QW (CLIA waived test) appended to the test code.

Exception: The tuberculin skin test does not require CLIA status. You may simply code this with 86580 (Skin test; tuberculosis, intradermal) and V74.1 (Special screening examination for bacterial and spirochetal diseases; pulmonary tuberculosis) when your FP performs it.

You might order several other lab tests, such as PKU for the newborn metabolic/hemoglobin screening, and screenings for lead, sexually transmitted infection (STI), and cervical dysplasia. But because an outside lab analyzes these tests, you will probably not report the tests- CPT laboratory codes.

Exception: If you have a lab agreement, under which your office bills for tests that the reference lab performs, you would use the CPT code appended with modifier 90 (Reference [outside] laboratory).

Even if the lab bills the analysis, you can still code any related collection that staff perform to conduct the test, such as a finger/heel stick (36416, Collection of capillary blood specimen [e.g., finger, heel, ear stick]) or routine venipuncture (36415, Collection of venous blood by venipuncture) linked to the screening diagnosis.

If you perform a pelvic exam, such as for a sexually active teenager, include the service in the preventive medicine service (for example, 99394, Periodic comprehensive preventive medicine - adolescent [age 12 through 17 years]). This includes collection of a Pap smear specimen.

-- Answers to You Be the Coder and Reader Questions reviewed by Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.