Pediatric Coding Alert

Question: Our pediatrician saw a patient who is putting on weight but whose body mass index (BMI) has not yet reached obese levels and who has no conditions that would lead to the weight gain. The pediatrician counseled the patient about the weight gain and nutrition. Do we bill this with 97802, or is there another way we should report this to a payer?

New York Subscriber

Answer: CPT^® code 97802 (Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes) would not be appropriate in this circumstance for two reasons. First, the patient would need to have a diagnosis such as Z68.53 (Body mass index (BMI) pediatric, 85th percentile to less than 95th percentile for age) or Z68.54 (... greater than or equal to 95th percentile for age) to justify the service. As the pediatrician has not provided a diagnosis of any kind, you cannot bill for it.

Second, 97802 services are more appropriately billed by a certified nutrition counselor. So, unless your pediatrician is certified, you would not be able to report the code for the counseling.

Without a diagnosis, you would also not be able to use an office/outpatient evaluation and management (E/M) code from 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …). Instead, as the patient is receiving the service to prevent future problems from developing, and as the sole purpose of the encounter is to maintain health, the most appropriate code to use in this scenario is 99401-99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …).

Remember: The codes are time-specific, so you will need to make sure you document how much time your pediatrician spent discussing the patient’s condition with the patient and select the correct code accordingly.