Pediatric Coding Alert

Reader Question:

Count on the Descriptors to Consider Chronic Conditions

Published on Thu Nov 10, 2022

Question: We are just starting to bill for chronic care management time. Is a developmental delay counted as a chronic condition. This patient has to go to PT and OT for services.

Oregon Subscriber

Answer: Essentially, whether the developmental delay can be billed as a chronic condition depends on the condition. The full descriptor for 99491 and add-on code +99437 reads:

Chronic care management services with the following required elements:

multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
comprehensive care plan established, implemented, revised, or monitored,
first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.

From how this is worded, it looks like 99491 (and the add-on +99437) may only be billed for specific management activities for “...Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

Therefore, if the clinician would characterize the patient’s developmental delay that way, the management activities may be reportable. For example, global development delay (GDD) is sometimes implicated in life-threatening conditions in newborns and therefore might qualify as chronic in some situations.