Pediatric Coding Alert

It sounds simple, but it's easier said than done: If you're not keeping track of the extra time you're spending providing services to children with serious chronic conditions, you're losing out on hard-earned reimbursement for patients who can consume lots of a pediatrician's time and energy.

But take heart. A thorough grounding in the spectrum of CPT codes available for children with significant long-term chronic problems, such as children with spina bifida, cystic fibrosis and cerebral palsy, will help you capture pay for the services you're providing these patients. According to the American Academy of Pediatrics'(AAP) coding guide, "Coding for Pediatrics 2003," the CPT codes for children with special healthcare needs are the same as for children without chronic conditions. Even so, it's up to pediatricians to determine how best to use code groups such as the prolonged services, case management and preventive services codes to report care they provide for chronically ill children. Pediatric coding experts suggest using the following code groups and offer seven tips for fine-tuning your chronic healthcare coding accuracy. 1. 99201-99215:Record Time of Highest-Level E/M Visits To accurately report problem office visits for new and established patients with chronic illnesses, pediatricians should remember to use time spent during the visit to select the higher-level E/M codes.

The time physicians spend with many of these patients exceeds the typical times included in CPT, even at the highest levels, says Richard A. Molteni, MD, FAAP, vice president and medical director at Children's Hospital and Regional Medical Center in Seattle. Molteni recommends using the "consultation rule" when more than 50 percent of the visit involves counseling or coordination of care (which is extremely common in these patients) to reach the highest E/M level when the degree of history or physical exam would not allow that. If, for instance, a pediatrician sees an established, wheelchair-bound spina bifida patient in the office for chronic constipation and spends a total of 40 minutes, with 25 minutes of the visit spent on counseling the patient and her mother on disimpaction methods, you would report 99215. Physicians should also be especially vigilant about reporting the correct ICD9 Codes because these support medical necessity for higher-level E/M codes.

The problem is that pediatricians have been coding for the acute events and not for the chronic illness, says Peter Rappo, MD, FAAP, a practicing pediatrician and assistant clinical professor of pediatrics at Harvard University School of Medicine.

"If you think the chronic illness diagnosis has an impact on the acute illness diagnosis, then you should code both," Rappo says. "When a child with spina bifida (741.9x) has recurrent ear [...]