Wiki Pediatric Nutrition/Wellness Coding

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jhartung

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I have a pediatrician who is having difficulties with procedure codes. She runs a practice focused on combatting childhood and adolescent obesity. The practice consists of Medical Assesment by the pediatrician to determine the patient's eligibility for the program, nutrition education, behavior modification, exercise and parent/child education and support. The pediatrician oversees everything. She performs an initial evaluation of the patient and then the patient returns twice a week for the excersize, counseling, behavior modification and nutrition education, which lasts for about an hour. She oversees all of this and is billing a 99214 twice a week for these "visits" as she spends roughly that amount of time interacting with the patients and their parents. She is concerned with documentation and wanted to make sure it is ok to charge that level of visit based on time. Does anyone know if there would be any other codes she should bill for rather than E&M codes?
 
I would look into the 99401-99404 codes. Check your cpt as these may be better than the e/m codes. Hope that helps. :)
 
Do you know if there are certain criteria for that set of codes? The provider is concerned that the insurances will only reimburse these once a year, just like the preventive medicine codes (99381-99397) and so that is why she has been using the office visit codes.
 
I am in no way an expert in this area. These are a few thoughts that I had while playing devil's advocate for this situation...

How are you justifying the documentation to meet the criteria of office codes 99211-99215? If the documentation is met, then why couldn't you bill these codes? Have you had any trouble getting these codes reimbursed from the insurance on a regular basis?

I agree with HBULLOCK that the codes 99401-99404 seem much more appropriate for the services you described. Keep in mind to make code selections based on the services provided, regardless of insurance reimbursement. Try to maximize your reimbursement, but make sure you are doing so in an ethical and legal way.

Have you considered getting pre-authorizations for these patients for these services so that you can bill 99211-99215 or 99401-99404 on a regular basis and expect reimbursement? I realize that I do not know how many patients you are providing these services to and that this could become quite time consuming. However, some insurance companies will issue pre-authorizations for a specific length of time. Example: Pre-Authorization for 99402 to be performed twice weekly for 11/01/2011-10/31/2012.

I don't know that 99401-99404 would be considered preventative medicine in the same aspect as 99381-99397 because of the code descriptions. 99381-99397 include "evaluation and management" while 99401-99404 include "counseling".

I don't know if any of this makes sense, or only caused more questions. I hope it helps in some way though!
 
Thank you so much for your insight, I do not work at this practice, I am being consulted so I am unsure of how all of this is being handled, but your thoughts and advice are extremely helpful. Thanks again! :)
 
We looked into providng nutritional counseling as well. I fouund that the codes 99401 thru 99404 were to be used prior to the diagnosis of obesity. They are listed as preventive medicine counseling and/ or risk factor reduction interventions. The services are face to face with the provider.

The nutrition counseling itself, if performed by a nutritionist, would fall under with 97802 (initial visit) or 97803 (subsequent).
 
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