Primary Care Coding Alert

Also: get clarification on the differences between screens and tests.

As primary care coders, you see medical notes for patients of many different ages. However, because a number of ICD-10 and CPT® codes are specific to your younger patients, you may find yourself doing a lot of second-guessing and cross-referencing.

To help you out, we’ve collected many common codes specific to kids you can review and reference as needed.

Know Your Preventive Medicine Services CPT^® Codes

The comprehensive preventive medicine services codes 99381-99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient...) and 99391-99394 (Periodic comprehensive preventive medicine reevaluation and management of an individual... established patient) refer to well-child visits, which, as noted, include an age and gender appropriate history and physical examination, and appropriate anticipatory guidance and risk factor reduction interventions.

Ages 0-4: For patients up to and including 364 days old, turn to 99381/99391. For patients aged one to four years, you should report 99382/99392.

• 99381/99391 (new/established patient… infant (age younger than 1 year))
• 99382/99392 (… early childhood (age 1 through 4 years))

Newborn coding alert: “For patients aged birth through 28 days, be aware that there are separate codes (99460-99463) to report normal newborn care,” says Kent Moore, Senior Manager for Payment Strategies at the American Academy of Family Physicians. “Per CPT® guidelines, these codes are limited to the initial care of the newborn in the first days after birth prior to home discharge. When newborns are seen in follow-up after the date of discharge in the office or other outpatient setting, then use 99381 or 99391, as appropriate if the visit is preventive in nature,” adds Moore.

Ages 5-17: Use the following codes for children aged five through 17. These codes will cover all the bases for school, sports, or work, as long as the provider thoroughly documents the visit, including growth and developmental milestones for younger patients and all the other age- and gender-appropriate components required.

• 99383/99393 (… new/established patient… late childhood (age 5 through 11 years))
• 99384/99394 (… adolescent (age 12 through 17 years))

Remember: “Most payers only pay for one preventive physical exam per year,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. This can get tricky when a patient has already had their yearly physical but now needs something for school sports, but if the patient had a preventive medicine exam within the past couple of months, you might be able to use the information gleaned from that visit to fill out a school/sports form. It should also be noted that if the provider deems the recent preventive exam current enough, just filling out the form does not warrant an evaluation and management (E/M) service code.

Corresponding Z-codes: When reporting the abovementioned well-child visit codes, also keep in mind the following diagnosis codes:

• Z00.110 (Health examination for newborn under 8 days old)
• Z00.111 (Health examination for newborn 8 to 28 days old)
• Z00.121 (Encounter for routine child health examination with abnormal findings)
• Z00.129 (Encounter for routine child health examination without abnormal findings)
• Z02.0 (Encounter for examination for admission to educational institution)
• Z02.4 (Encounter for examination for driving license)
• Z02.5 (Encounter for examination for participation in sport)

Coding alert: Look to payer guidelines for age-specific diagnosis coding rules. For example, Z00.12- (Encounter for routine child health examination) or Z00.0- (Encounter for general adult medical examination) are subject to age-specific Medicare Code Edits (MCEs), which instruct you that Medicare will reimburse for a Z00.12- code only for patients from the age of 0 through 17 years old (which it defines as “pediatric”), and a Z00.0- code for patients 15 through 124 years of age (which it labels “adult”). (Source: www.cms.gov/medicare/coding/icd10/downloads/icd10_mce27_user_manual.pdf)

Check Out Developmental and Behavioral/Emotional Screens …

These are two of the most common codes providers use to assess young patients:

• 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument)
• 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument)

It’s common for family medicine coders to not fully understand when to use one code over the other. “Developmental screenings really look at a patient’s overall development and will include questions on motor skills, language skills, cognitive function, and possibly questions on social, emotional, and behavioral issues,” notes Jessica Miller, CPC, CPC-P, CGIC, manager of professional coding for Ciox Health in Alpharetta, Georgia. “An emotional or behavioral assessment instrument will look specifically at behavior and emotional health related to key symptoms of behavioral or emotional conditions, such as ADHD [attention deficit hyperactivity disorder], depression, or anxiety,” Miller adds.

Remember: If your physician collects information about the child’s development as part of a history during a sick or well evaluation and management (E/M) service, this is regarded as surveillance and “not formal ‘screening’ as such, and is not separately reportable” according to the American Academy of Pediatrics (AAP) (Source: https://downloads.aap.org/AAP/PDF/coding_factsheet_developmentalscreeningtestingandEmotional­Behvioraassessment.pdf).

Also, your physician must use a standardized instrument in order for you to report a formal screening such as the one represented by 96110. Examples of such tools include the Ages and Stages Questionnaire (ASQ), the Pediatric Evaluation of Developmental Status (PEDS), or the Modified Checklist for Autism in Toddlers (M-CHAT).

For a comprehensive list of standardized screening tools, go to the AAP’s Screening Time website at www.aap.org/en/patient-care/screening-technical-assistance-and-resource-center/. You can filter the list by such categories as early childhood development, development, autism, and adolescent depression.

Coding alert: Typically, clinical staff perform 96110 and 96127 services. This is reflected by the Medicare valuation of the codes, which do not include physician work values.

… And How They Differ From Developmental Tests

The American Academy of Pediatrics (AAP) describes the difference between screens and tests like this: “Screening asks a child’s observer to provide his/her observations of the child’s skills, which are then recorded on a standardized and validated screening instrument. Screening is subjective and only reports the assessment of the patient’s skills through observation by the informal observer. On the other hand, testing measures what the patient is actually able to do on a standardized psychometric instrument at that time.”

Turn to the following codes to report developmental testing:

• 96112 (Developmental test administration (including assessment of fine and/or gross motor, language, cognitive level, social, memory and/or executive functions by standardized developmental instruments when performed), by physician or other qualified health care professional, with interpretation and report; first hour)
• +96113 (… each additional 30 minutes (List separately in addition to code for primary procedure))

E/M coding alert: Screening and testing services can be billed with any E/M service, whether it be a preventive or a sick visit E/M if the documentation supports it. Per AAP, you would do this by appending modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M or modifier 59 (Distinct procedural service) to the screening or test code.

Caution: Watch out for double dipping with 96112/+96113. If you do report an office/outpatient E/M with these codes, make sure you do not count the time and effort in conducting the testing toward the medical decision making (MDM) or time in your E/M selection.