AAPC Knowledge Center

Words of Wisdom for Pediatric Preventive Care Claims

Pediatrician and little patient

Knowing which services are included and which are separately reportable ensures appropriate reimbursement.

By Cindy Hughes, CPC, CFPC
In the first years of life, preventive services play an important role in determining if a child is growing and developing as expected. And for these services, payer rules play an important role in being reimbursed appropriately. Here’s some wise advice on how to do it.

Recommendations for Preventive Services 

Most physicians and other qualified healthcare professionals (QHPs) provide pediatric preventive services based on Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition. These guidelines include recommended preventive services for each age, starting at birth (or in some cases starting during the prenatal history and anticipatory guidance) and ending at age 21 years.
Although some preventive services are included in the pediatric preventive evaluation and management (E/M) services (99381-99385 and 99391-99395) others are separately reported. It’s important to know the difference.

Services Not Separately Reported

All preventive E/M services include an age- and gender-appropriate history and examination. Do not separately report elements of the history or examination unless related to a significant, problem-oriented E/M service or directed by payer policy.
For example, the preventive service for a 16-year-old female is likely to include breast and pelvic examinations (screening for cervical cancer is not recommended), so these typically are not separately reported. Insignificant E/M of problems (e.g., mild diaper rash, typical behavior issues) are not separately reported. Anticipatory guidance and counseling for risk factor reduction (99401-99404, 99411, and 99412) are included in preventive E/M services when provided at the same encounter. Preventive counseling may include topics such as diet, exercise, home and travel safety, and substance use avoidance.

Separately Reportable Services

Variations in payer policies and bundling edits make knowing which services are separately reportable more difficult; but not billing for
separately paid services may result in significant revenue left unclaimed. To know what is separately reportable, check CPT® guidelines.
As per CPT® instruction, childhood preventive E/M services do not include:

Modifier 33 Preventive service may be required for services, such as laboratory testing, to identify the preventive purpose of the testing (e.g., depression screening in an adolescent, 96127-33). Not all payers recognize modifier 33 for payment.
When counseling and/or risk factor reduction services are provided on dates when no preventive medicine E/M service described by codes 99381-99385 or 99391-99395 is provided, report 99401-99404 based on the time of service. Time is met when the midpoint is passed (e.g., 8-15 minutes of service supports code 99401 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes). For preventive counseling or risk factor reduction provided to a group of patients, see codes 99411-99412.

Vaccine Administration

In general, both the vaccine product and administration are paid when immunizations are provided. Codes for immunization administration include:
Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
Codes 90460-90461 are reported only when:

Report one unit of 90460 for each vaccine product administered to a patient 18 years and under with physician/QHP counseling. Report one unit of 90461 for each additional component of a single vaccine product (e.g., one unit of 90460 and two units of 90461 for a measles, mumps, and rubella vaccine).
Report all other immunization administrations (i.e., to patient 19 years and older or provided without physician/QHP counseling) with codes 90471-90474. Only one initial immunization code (90471, 90473) is reported on a single date of service.
National Correct Coding Initiative (NCCI) edits bundle codes 99381-99385 and 99391-99395 to each of the immunization administration codes when reported on the same date. It’s necessary to append modifier 25 to the E/M service to indicate a significant and separately identifiable service.
Be sure to follow state-specific coding requirements for immunizations using vaccines supplied through the Vaccines for Children Program.

Diagnosis Codes and Linking

In age order, ICD-10-CM codes for routine preventive examinations are:
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 [over 28 days old] health examination with abnormal findings
Z00.129 Encounter for routine child health examination [over 28 days old] without abnormal findings
Z00.00 Encounter for general adult medical examination without abnormal findings
Z00.01 Encounter for general adult medical examination with abnormal findings
Although state regulations vary on when a child becomes an adult, codes Z00.00-Z00.01 may be required by payers for patients 18 years and older. Payers may also apply age edits to other ICD-10-CM and/or CPT® codes for preventive services.
When choosing between codes for health examination with or without abnormal findings, report “with abnormal findings” when a physician documents a new abnormal finding or a pre-existing condition that is unstable or worsening.
The aforementioned ICD-10 codes include routine vision, developmental, and hearing screening services and no additional diagnosis code is required. Code Z23 Encounter for immunization is reported in addition to the code for the routine child health exam (Z00.121 or Z00.129) when reporting immunization services. Link the claim line for the immunization service to both Z00 and Z23.
Payers may also require specific ICD-10-CM codes linked to the related service in field 24E of the CMS-1500 claim form for certain screening services, such as:

Look also for advantages of reporting diagnosis codes that show quality of care and support the payer’s need for data on measures such as counseling for diet (Z71.3 Dietary counseling and surveillance) and physical activity (Z71.82 Exercise counseling). Other codes commonly reported include body mass index, such as:
Z68.51 Body mass index (BMI) pediatric, less than 5th percentile for age
Z68.52 Body mass index (BMI) pediatric, 5th percentile to less than 85th percentile for age
Z68.53 Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age
Z68.54 Body mass index (BMI) pediatric, greater than or equal to 95th percentile for age

Payer Guidelines

Since the implementation of plans with no out-of-pocket cost for recommended preventive services under the Affordable Care Act, many payers have published preventive service reimbursement/payment policies with specific coding requirements. These vary by payer and plan, so be sure to verify policies and code edits whenever possible.
Coding and modifier requirements may vary even within Medicaid programs of one state. If applicable, be sure your practice is aware of guidelines for Early and Periodic Screening, Diagnostic, and Treatment Program services for each Medicaid contractor. Medicaid plans may cover services that other plans do not (e.g., many cover maternal depression screening at well-child visits).
Like most coding topics, preventive medicine coding is complex. Knowledge of CPT® instruction and the reimbursement policies of your practice’s most common payers will make code selection easier and help prevent improper payment.

Identifying Problem-oriented Services

A preventive service does not include a chief complaint, history of present illness, or problem-oriented history. When determining if a problem addressed during a preventive E/M service warrants a separate E/M code (e.g. 99213-25 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity- 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), look for documentation elements that are intended to further identify findings related to a complaint, rather than to identify patient risk factors. For examples of age and gender-appropriate preventive past, family, and social history and review of systems, see the Bright Futures core tools for each age group in the Resources section.
Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 4th Edition: https://brightfutures.aap.org
Bright Futures core tools for each age group:
AAPC Knowledge Center, “Vaccination Administrations in Pediatric Practice:”

Cindy Hughes, CPC, CFPC, is a consulting editor contributing to medical coding publications including the AAP Pediatric Coding Newsletter™ and Family Practice Management magazine. She is new to the Wichita, Kans., local chapter, having relocated after enjoying many years of participation in the activities of the Kansas City, Mo., chapter.

Words of Wisdom for Pediatric Preventive Care Claims was last modified: December 11th, 2021 by Guest Contributor

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