Pediatric Coding Alert

Question: A 15-year-old established male patient reports to the pediatrician for his annual physical. Encounter notes indicate that the provider also took a complete lipid panel during the encounter. How should I report this encounter?

Texas Subscriber

Answer: You should be able to report a pair of codes for this encounter. On your claim, report

• 99394 (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; adolescent [age 12 through 17 years]) for the preventive service
• 80061 for the lipid panel
• Modifier QW (CLIA waived test) appended to 80061 to show that you are coding for a clinical laboratory improvement amendments (CLIA) waived test — if the payer requires it.

Remember: In order to report 80061, the provider must obtain the following measurements during the panel:

• Cholesterol, serum, total;
• Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol); and
• Triglycerides.

If the provider does not obtain all three of these measurements during the lipid panel, don’t report 80061; instead, report the measurements separately. So, let’s say that notes indicate the pediatrician performed a preventive medicine visit and a panel consisting of total cholesterol serum and triglycerides, you’d report

• 99394 for the preventive service
• 82465 (Cholesterol, serum or whole blood, total) for the cholesterol panel
• 84478 (Triglycerides) for the triglycerides panel
• Modifier QW appended to 82465 and 84478 to show that you are coding for a CLIA-waived test — if the payer requires it.

Why pediatricians? Most of the time, lipid panel tests happen in a cardiologist’s office. There are times, however, when a pediatrician will detect an underly­ing systemic issue that prompts her to perform a lipid panel. Many times, these diagnostic services occur when a patient presents for a well visit such as an an­nual physical.