Pediatric Coding Alert

And make sure you have a policy in place.

“The only constant in life,” an ancient philosopher once observed, “is change.” As they navigate the physical and developmental transitions from childhood to adulthood, adolescents know this all too well.

As a part of that change involves them transitioning out of pediatric and into adult medicine, the observation holds true for coders, too. But the following guide assembles all the codes you need to document that change and help that transition go as smoothly as possible for your patients and your practice.

Use These 6 Elements to Make the Change

Before you say goodbye to your grown patients, it’s a good idea for your provider and practice to have a policy in place to ensure a seamless transition.

Fortunately for pediatric practices across the country, two organizations, the Maternal and Child Health Bureau and The National Alliance to Advance Adolescent Health, have created a comprehensive resource, “Got Transition,” to help ease their teenage patients into the world of adult medicine. In particular, the resource outlines six core elements to help your office facilitate the change:

• Establish a transition policy.
• Track and monitor the patient.
• Determine the patient’s readiness for the transition.
• Plan the transition.
• Transfer patient to an adult model of care.
• Complete the transfer (Source: www.gottransition.org/resourceGet.cfm?id=208).

“According to the American Academy of Pediatrics, the age of transition from pediatric well-care to adult well-care should be left up to the patient and/or family,” says Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico. “Fortunately, from a coding perspective, the transition need not be problematic, as either a pediatrician or other physician who provides such care need only know the age cut-off for the CPT^® codes,” Witt elaborates.

What Codes Come Into Play for a Simple Transition?

While there are no specific codes to document the change, “depending on when this transition occurs, the codes best suited for such a service would be the preventive service codes,” says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh. For many adolescent patients, that would happen during their final preventive medicine visit with their pediatrician.

That means “the codes that would most frequently be reported in this transition period by either the pediatrician or another provider type,” according to Witt, would include 99384/94 (Initial/periodic comprehensive preventive medicine reevaluation and management of an individual …; age 12 through 17 years) or 99385/95 (… 18-39 years).

Use 96160 to Assess Patient Readiness

Along with 99394/5, you can also use 96160 (Administration of patient-focused health risk assessment instrument (eg, health hazard appraisal) with scoring and documentation, per standardized instrument) to document that your pediatrician or staff member has administered a scorable transitional readiness form (such as the one featured on the “Got Transition” website at www.gottransition.org/resourceGet.cfm?id=224) to assess patients’ understanding of their own health, how to use the healthcare system, and their preparedness for the transition to adult health care.

Your staff can use the instrument regardless of whether the patient is new or established, and even though the code’s descriptor uses the words “risk” and “hazard,” you can use the code whether or not the patient suffers from a chronic condition. Just remember to add 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 to indicate that the preventive medicine visit is a separate service to the 96160.

Moving Up Without Moving Out

Of course, not all transitions involve peds patients moving out of a pediatric practice. “The patient can stay within a practice, going from a pediatrician within the practice to an internal medical or family medicine provider,” Hauptman reminds coders. In this case, the patient would still be regarded as an established patient within the practice providing the patient meets the CPT^® definition and has received “professional services … [in] the same group practice within the past three years.”

But “if the specialties are different, and the providers are enrolled as such with the payers, the visits will be new,” Hauptman concludes.