Pediatric Coding Alert

By A.D. Jacobson, MD, FAAP

This months columnist, A.D. Jacobson, MD, FAAP, is chairman of the American Academy of Pediatrics (AAP) section on administration and practice management and a full-time pediatrician as well as a coding expert. He served on the AAPs coding and reimbursement committee, and is past editor of the AAPs Coding for Pediatrics. He practices with Pediatric Associates, a four-pediatrician practice in Phoenix, Ariz.

Without the code, theres no reimbursement. Thats why pediatricians need to be conversant with CPT. But they also need to think creatively because not all scenarios immediately fall within the strictures of CPT. There are so many factors that go into real-life situations with which the language of CPT may not seem to jive. But it doesits just a matter of getting to know the lingo. In the coding tips below, I have included some examples that may help illustrate the gray areas.

1. Prenatal counseling service. This is an area that many pediatricians become confused about when it comes to coding. Sometimes, the only option seems to be to provide the service for free and to consider it a marketing tool. But there are ways to bill for this service. First, you can use the counseling and risk factor reduction codes (99401-99404). Secondly, you can use the confirmatory consultation codes (99271-99275). For these codes, you do not need a referral from a provider. The patient can self-refer based on what her obstetrician has told her. Finally, you can use the consultation codes (99241-99245) if the obstetrician has referred the woman to you for prenatal counseling. Often, the diagnosis is of an intrauterine condition, and the obstetrician wants the mother to talk to you. You should bill the appropriate diagnosis code to the mothers insurance because there is no child yet. For other prenatal visits, such as with moms who want to talk about circumcision, breast-feeding or other general issues, the style of our practice is that we do not bill. We regard these visits as good public relations and marketing.

2. Time. Dont forget that time can be used as a factor in choosing the level of evaluation and management (E/M) service if counseling and/or coordination of care account for more than 50 percent of the face-to-face time with the patient. Pediatricians should enter the total duration of counseling and/or coordination of care into the clinical notes, as well as a description of the counseling and/or coordination of care taking place.

For example, a 2-year-old child comes into the office for a sick visit and is diagnosed with otitis media. The history and physical and decision-making would qualify for a CPT 99213 . The mother, however, requests counseling from the physician because of an [...]