Pediatric Coding Alert

These dos and don’ts will give your reporting a healthy outcome.

An ounce of prevention, as the old saying goes, is worth a pound of cure. Nowhere is that truer than in the preventive medicine services your pediatrician provides for the adolescent patients in your practice, who often need medical guidance to help them deal with the physical and psychological changes they are undergoing.

For coders, this means understanding the different ways to code preventive medicine services for this population, as well as understanding the guidelines for coding each kind of service your pediatrician provides.

In this brief guide, we’ll look at both preventive medicine codes and codes for behavior change interventions and risk-factor reduction, along with the dos and don’ts behind reporting them.

When Documenting Well Visit Services …

Per the CPT^® descriptors, preventive health visits for any age group include a number of elements that are aimed at “counseling, anticipatory guidance, and risk-factor reduction interventions.” For adolescents, code these visits using the following:

• 99384 — Initial comprehensive preventive medicine evaluation and management of an individual … new patient; adolescent (age 12 through 17 years);
• 99385 — Initial … new patient; 18-39 years;
• 99394 — Periodic … established patient; adolescent (age 12 through 17 years);
• 99395 — Periodic … established patient; 18-39 years.

Do This …

Report any age-appropriate vaccinations and laboratory or diagnostic procedures your provider administers during these encounters. Remember, “the guidelines preceding these preventive visit codes in CPT^® state, ‘Vaccine/toxoid products, immunization administrations, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg, vision, hearing, developmental) identified with a specific CPT^® code are reported separately,’” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

So, for example, you can separately report and bill CPT^® codes for immunization administration and vaccine risk/benefit counseling such as 90460 and +90461, codes for immunization administration without counseling (90471-+90474), vaccine/toxoid products such as 90476-90749, hearing tests, and fecal occult blood tests.

Depending on the nature of the counseling, you should also attach the appropriate encounter code from the Z69-Z76 (Persons encountering health services in other circumstances) block of ICD-10-CM.

… But Don’t Do This

Code for preventive medicine services if the encounter is problem-focused. “Well care does not have a chief complaint or medical decision making,” Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, reminds coders.

This point is echoed by the American Association of Pediatrics (AAP), which notes that “counseling or interventions are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.” In other words, the AAP continues, they “cannot be reported with patients who have symptoms or established illness.”

When Coding for Behavior Change Interventions, Risk-Factor Reduction …

Should the patient require some form of help for current lifestyle problems, it would then be appropriate for your pediatrician to provide some kind of intervention. These can take numerous forms, but the following codes describe the most frequent screens and services:

• 99401-99404 — Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual …
• 99406 — Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes
• 99407 — … intensive, greater than 10 minutes
• 99408 — Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to 30 minutes
• 99408 — … greater than 30 minutes.

Do this …

Verify with your payer that it will cover the services. Remember that “one of the disadvantages of 99401-99409 is that these codes may or may not be covered by insurance carriers,” according to Holle.

You’ll also need to use 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 indicate that there was a separate identifiable evaluation and management [E/M] service performed at the same time,” says Holle.

Depending on the nature of the problem, you also need to attach the appropriate ICD-10-CM code. That would mean choosing from Z87.891 (Personal history of nicotine dependence) for the tobacco use dependence, adding the codes for alcohol abuse and dependency (F10.-), drug abuse or dependency (F11-F16, F18-19), or nicotine dependence (F17.-) as appropriate per the encounter code guidelines.

… But Don’t Do This

Separately report counseling and risk-factor reduction interventions such as 99401-99409 in addition to 99384/99385/99394/99385, warns Moore. And, as 99401-99409 are timed codes, Holle reminds coders that “the amount of time has to be documented in the note as well as a brief synopsis of what was discussed and the plan.”