Pediatric Coding Alert

Age, history, risk factor, and vaccinations set these E/M visits apart.

It's safe to say that evaluation and management (E/M) visits make up the largest percentage of the visits to your practice. It's also safe to say that many of them are also preventive wellness, or reevaluation and management, visits.

But as similar as the visits may be, it's important to remember how much they differ, and how those differences may affect the way you document the encounters. So, take the following refresher course and make sure you know the specifics of preventive medicine coding.

Document Preventive When Service is not Problem Focused

Coders should first determine whether the visit should be coded as preventive medicine using 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual ...) or 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual ...), or an E/M visit with 99201-99205 (Office or other outpatient visitfor the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visitfor the evaluation and management of an established patient ...).

To make that decision accurately, Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, offers coders this simple piece of advice: "well care does not have a chief complaint or medical decision making."

Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh, agrees, reminding coders to scrutinize the documentation "for evidence of a particular condition that is of concern to the patient, parents, or provider. If the problem is significant," Hauptman insists, "it should be conveyed appropriately within the documentation and might warrant an E/M service in addition to, or instead of, the preventive service."

In this case, "if the documentation also indicates a thorough preventive service," Hauptman suggests "adding 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 service will illustrate to the payer that both services were separate and significantly identifiable."

Document Preventive When Exam is Age- and Gender-Appropriate

Next, coders should also look through the documentation to determine the purpose of the exam provided by your pediatrician during the course of the encounter. As Hauptman explains, for a problem-focused E/M, "the history, exam, and decision-making should clearly point to the problem and its potential resolution."

Holle agrees, providing the reminder that "a comprehensive history in well care is not the same as a comprehensive history in a sick visit, which has three key factors - a history, an examination, and medical decision making - that vary in complexity and that have to be met to justify different levels of care that are very specific per level."

For preventive exams, however, CPT^® guidelines specifically state that "codes 99381-99397 reflect an age and gender appropriate history/exam." For pediatric practices, that means:

• 99381/99391 - ... infant (age younger than 1 year)
• 99382/99392 - ... early childhood (age 1 through 4 year)
• 99383/99393 - ... late childhood (age 5 through 11 years)
• 99384/99394 - ... adolescent (age 12 through 17 years)
• 99385/99395 - ... 18-39 years

Document Preventive When Service Involves Risk Factor Counseling

Unlike a problem-focused E/M visit, wellness visits include an age-appropriate consultation component, which can address such issues as diet and exercise, sexual activity, family circumstances and relationships, and risk prevention. Holle provides the reminder that these visits are opportunities for special screenings like the Modified Checklist for Autism in Toddlers (MChat) or depression screenings for older children.

Hauptman, meanwhile, reminds coders that even though you cannot report counseling codes 99401–99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); ...) in addition to preventive medicine service codes, "looking to the other preventive services might make sense for reporting. For example, if the pediatrician discusses smoking cessation with an adolescent patient, and the time around that type of counseling is provided and can be clearly identified within the body of the documentation, it could be considered for reimbursement depending on the payer requirements."

Document Preventive When Service Requires Laboratory/Diagnostic Procedures

Finally, 99381-99387/99391-99397 visits are the time for your pediatrician to administer age-appropriate vaccinations. For these visits, Holle offers another reminder that they must be accompanied by counseling in order for you to bill 90460-90461 (Immunization administration through 18 years of age ...). If the provider does not offer counseling to the patient, you should document 90471-90474 (Immunization administration ...).