Pediatric Coding Alert

Diabetes, ADD, and asthma aren't always an E/M-only visit. Collect for your other services as well with these tips.

Stop missing opportunities to bring in extra payment when you perform care above and beyond an E/M service when treating children who have special needs. This quick primer will make sure you're all set to collect everything you document when seeing your patients.

Keep Continuum of Care in Mind With ADD

You can capture the initial service and ongoing visits for attention deficit disorder (ADD) and attention deficit hyperactivity disorder (ADHD), if you code based on a coding continuum of care.

Diagnosis, maintenance, interval checks and reassessment of ADD/ADHD with an established patient can be nurse-only, brief, or involved-physician visits. You'll start out when the pediatrician diagnoses a patient with ADD (314.00, Attention deficit disorder; without mention of hyperactivity) or ADHD (314.01, ... with hyperactivity) by typically looking at a high-level E/M service, such as a 99214 or 99215, particularly if you base your coding on the face-to-face time spent with the patient and/or family counseling and coordinating care.

Tip: Because counseling is usually a predominant component of ADD/ADHD initial diagnosis sessions, anticipate using time to code these encounters, which may take as long as an hour. Encourage the physician to document the counseling session's content, the total face-to-face time spent, and the time devoted to counseling/coordinating care related to the ADD/ADHD disorder. When over 50 percent of the total face-to-face encounter time is spent counseling or coordinating care, the code can be selected based on time alone.

Return visit: After a patient has been diagnosed with ADD/ADHD, he's going to have interval shorter visits on a scheduled basis. Pin down the appropriate-level office visit code for these interval sessions using this guide (these may be determined using time-based coding):

• 99212 -- a brief visit with medication refill
• 99213 -- a brief re-evaluation and medication refill
• 99214 -- a more extensive visit for interval concerns/parental concerns and medication adjustment or refill.

Revenue opportunity: The return visits may include a Vanderbilt ADHD standardized rating scale evaluation as included in the American Academy of Pediatrics' ADHD Toolkit to evaluate and assess the patient's progress. You should report this testing with 96110 (Developmental screening, with interpretation and report, per standardized instrument form). Although CPT does not require you to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the associated E/M code when reporting 9921x with standardized testing, some insurers may require this. If multiple tests are reviewed and discussed (parent, teacher), bill for each with 96110. The initial Vanderbilt form will be billed with 96110, and each additional form with 96110-59 (Distinct procedural service). Otherwise the subsequent tests will be denied.

Capture Face-to-Face Monthly Refills: Consider the next round of visits for ADD/ADHD as maintenance. These medication-management services may be based on any face-to-face encounter between the nurse and the patient.

If the patient comes into the office for an ADD/ADHD medication refill without a physician face-to-face visit, report a nurse visit (99211). During this visit, the nurse should provide an E/M service with an interval history, questions about the patient's sleeping and eating habits, and any school or behavior issues. This should all be carefully documented.

Know When 94664 is Billable for Asthma Patients

Don't write off training episodes when you teach a patient how to use a nebulizer or metered dose inhaler (MDI). Taking that simple step with your established patients can garner extra pay each time you report 94664 (Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device). Currently, the national adjusted Medicare fee for non-facility service is $17.02, so check your other payers' fee schedules. You can repeat education at future visits as necessary to ensure optimal use of an aerosol machine or metered dose inhaler.

Most insurers also allow you to report 94664 when training patients on how to use the Advair Diskus. This training should be separately documented by the health professional providing the training, and counter-signed by the physician as an incident-to service.

Example: A pediatrician starts a patient with asthma (493.00, Extrinsic asthma; unspecified) on Advair. A nurse then teaches the patient how to use the diskus. You should report 99201-99215 for the office visit and 94664 without a modifier, according to CPT guidelines. CMS transmittal R954CP also indicates that modifier 25 applies only to E/M services performed with procedures that carry a global fee, which 94664 does not have.

Beware: Before dropping modifier 25 from 99201-99215 with 94664, check with your major insurers. Some payers may require modifier 25 appended to the E/M when performed with 94664 or any "pulmonary service."

During the teaching, the patient may receive a medication dose. In this case, you should not separately report the treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device]).

If, however, the patient was treated with an aerosol for acute wheezing and separate instruction follows when the pediatrician decides to send the patient home with an aerosol machine, bill the following: 94640 and 94664-59 for the training. Otherwise, the payers will assume that the training was included in the aerosol that was given.

Reason: The administration was performed as part of the demonstration/evaluation, and the service's intent was patient teaching.

Performing MNT for Diabetic Patients? Follow This Advice

Pediatric practices are increasingly performing medical nutrition therapy (MNT) and diabetes education provided by a registered dietitian, but many practices aren't charging for these services because they aren't sure how to bill them. Here's a five-step primer on how you can collect.

Step 1: Choose Between CPT and HCPCS Codes. When an individual certified nutritionist consults with a patient in a noncertified physician setting, you'll most likely report diabetic sessions with 97802-97804. But if your practice has an American Diabetes Association-approved program, you may also use Medicare-specific codes G0108-G0109.

Here's how: For noncertified programs, select the nutrition session code provided by the registered dietitian based on the patient's diagnosis and the number of individuals involved. Use 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) for initial medical nutrition therapy involving a single patient.

Report a follow-up patient session with 97803 (... re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes). For group sessions, assign 97804 (... group [2 or more individuals], each 30 minutes).

Example: After a pediatrician diagnoses a patient with diabetes and orders MNT, the practice's certified nutritionist meets with the patient for a 45-minute initial assessment and intervention. The patient later returns for a two-hour group session that involves re-assessment and intervention. You should report the initial session with three units of 97802 and the group follow-up session with four units of 97804. One unit of the individual code represents 15 minutes, and a group unit consists of 30 minutes.

To code ADA-certified diabetes self-management training (DSMT) sessions, determine how many patients attended the service. Code individual sessions with G0108 (Diabetes outpatient self-management training services, individual, per 30 minutes). When two or more patients attend the session, assign G0109 (Diabetes self-management training services, group session [2 or more], per 30 minutes).

Step 2: Report Under the Nutritionist's ID Number. Prompt payment for MNT sessions depends on avoiding one common filing mistake: reporting these sessions as incident-to. Because 97802-97804 are nutritionist-specific codes, you should not report these codes incident-to a physician. Instead, use the nutritionist's NPI.

Step 3: Verify Coverage Limitations. If you're using the correct MNT/DSMT code and associated PIN, but your payer is still denying claims, double-check the insurer's coverage limitations. Some insurers allow a one-hour initial MNT visit and two hours of follow-up after the initial visit in the first year. Other coverages vary.

Step 4: Check Diagnostic Requirements. To ensure nutrition therapy coverage, check the documentation to be sure that the patient's diagnosis is listed as a covered condition according to the insurer's policy. If your insurer does not cover the documented diagnosis listed in the patient's chart, let the patient or patient's family know up-front that the MNT may not be a covered service, and that they will be responsible for payment for these services. Ideally, an ABN (advance beneficiary notice) should be signed documenting that they are aware of this requirement.

Step 5: Make Sure the Referral Is Clear. Many insurers, particularly HMOs, will not reimburse for MNT or DSMT unless the treating physician provides a written referral for the service. When you bill an HMO for nutrition counseling, make sure you have a physician's referral on file.