Pediatric Coding Alert

Question: We have a new pediatrician who has scheduled several 30-month visits. How can we get reimbursed for these? If so, how do we handle them?

Answer: The Bright Futures/American Academy of Pediatrics “Recommendations for Pediatric Health Care” recommend a 30-month preventive medicine service. You should code these based on the patient’s status as new or established. Keep in mind, however, that payment and evidence-based preventive medical standards are not the same thing.

A patient is established if he has received professional services from your pediatric group in the last three year (since he was born). For a 30-month preventive medicine new patient visit, use 99382 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; early childhood [age 1 through 4 years]). Code an established patient preventive medicine service as 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood [age 1 through 4 years]).

Payment will depend on the patient’s insurance and covered benefits, and you should avoid surprising your patients and families. Keep two tips in mind when deciding whether to provide 30-month visits:

• Create a spreadsheet showing the number of visits your major payers cover each year. Some payers cover only one visit per year for 2- and 3-year old beneficiaries, so check the frequency coverage up-front.
• When you schedule the appointment, explain that insurance might not cover the exam but that the AAP recommends this preventive periodicity schedule as optimal evidence based care. It is an optimal time to assess language development and communication. The parent can either opt out of the visit or sign a private payer version of Medicare’s advance beneficiary notice (ABN) stating the parent will be responsible if insurance denies payment.