Alphabetical Index of Topics |
||
| After Hours | ||
| Excessive Crying, Infant | Hib | Strep culture, overnight |
| Flumist | Menactra | |
Coding
Welcome to our Coding Page! The Practice Advisory committee is compiling codes which have posed issues over the last few months. The Alphabetical Index below will bring you to the code, and the codes are in numerical order so that you may scroll down to them to search by code.
Below this is a Summary of the ICD-9-CM codes that are relevant for pediatricians, alphabetically listed. It includes about 70% of the codes on the AAP ICD-9-CM flip-chart. The following ICD-9 codes should be used as of October 1, 2009. Also, do not use the codes that have been deleted. As always, the problem will be those companies that will REJECT any claims that use the deleted codes and/or do not use the more specific codes. The converse, unfortunately, is also true – there will be companies that do not implement the updates for several months. Have staff be aware of this when a claim is not paid, or rejected without a clear explanation as to why. There are many new E-codes – but they are never for the primary diagnosis. New and deleted CPT codes will be available for 1/1/2010.
Alphabetical Index of Topics |
||
| After Hours | ||
| Excessive Crying, Infant | Hib | Strep culture, overnight |
| Flumist | Menactra | |
IMPORTANT: CODING FOR H1N1:
779.32-Other vomiting
779.34 - Failure to thrive
784.42 - Hoarseness
784.59 - Other speech disturbance
780.91 - Fussy infant (baby)
784.51 - Dysarthria
784.59 - Other speech disturbance
787.04 - Vomiting
789.7 - Colic
799.21 - Nervousness
799.23 - Impulsiveness
799.82 - ALTE
813.46 - Torus (Buckle) fracture
813.47 - Torus (Buckle) fracture + radius
832.2 - Nursemaid elbow
87070 - Oxford has been rejecting the
overnight strep code 87060. The new code is 87070. If you receive
rejections for this code, accumulate the information and either call or send
to the Trumbel, CT, office.
90465 - Immunization administration under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day. (Do not report in conjunction with 90467)
90466 - Each additional injection under 8 years of age (includes percutaneous, intradermal, subcutaneous or intramuscular injections) when the physician counsels the patient/family; (single or combination vaccine/toxoid), per day. List separately in addition to code for primary procedure. (Use in conjunction with 90465 or 90467)
90467 - Immunization administration under 8 years of
age (includes intranasal or oral routes of administration) when the
physician counsels the patient/family; first administration (single or
combination vaccine/toxoid), per day. (Do not report in conjunction
with 90465)
90645 - 906448 - MDNY is paying different
amounts for the various products 90645, 46, 47, and 48. Be aware of
the different reimbursements.
90732 - Pneumococcal Polysaccharide Vaccine
- GHI will sometimes reimburse for Prevnar under this code, but at a low
rate (less than $20).
99050 - Services provided in the office at
times other than regularly scheduled office hours, or days when the office
is normally closed (e.g., holidays, Saturday or Sunday), in addition to
basic service.
99051 - Services provided in the office during
regularly scheduled evening, weekend or holiday office hours, in addition to
basic service.
99056 - Services typically provided in the office,
provided out of the office at the request of the patient, in addition to
basic service (House Call).
99058 - Services provided on an emergency basis in the
office which disrupts other scheduled office services, in addition to basic
service.
99080 - This is for "special reports such
as insurance forms, more than the usual information conveyed in the usual
medical communications of standard reporting form." Use in with diagnostic
code V68.9 - "unspecified administrative purpose."
99371 - It should
be reported with the correct diagnostic code or codes. Additionally, there
should be a system in place for all calls to be documented in the patient's
chart. Some companies have paid.
99354 - Prolonged Service, outpatient,
face-to-face, first hour
99355 - Prolonged Service, outpatient, face-to-face, additional 30
minutes
99441 - This is the lowest level of three codes (99442, 99443) for use to report a telephone intervention. Telephone E/M service provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours, < 10 minutes.
99442 - ..., < 20 minutes.
99443 - ..., < 30 minutes.
99444 - Used to report an
on-line (e-mail) medical
evaluation, provided by a physician to an established patient,
guardian or health care provider as long as it does not address a problem
originating from an E/M service provided within the previous 7 days.
Although an RVU was proposed, the assigned value for 2008 is 0. (Please
note: 0074T has been Deleted!)
S0622 - Physical exam for college, new
or established patient.
S8100 - Holding chamber or spacer for
use with an inhaler or nebulizer; without mask.
S8101 - Holding chamber or spacer for use with an inhaler or nebulizer;
with mask.
S9986 - Not medically necessary service
(patient is aware that services not medically necessary)
V01.81 - Contact with or exposure to
communicable diseases, anthrax
V01.89 - Contact with or exposure to
communicable diseases, other communicable diseases
V15.83 - Lapsed Immunization schedule –
V15.89 - Other specified personal history presenting hazards to
health (exposure to tobacco smoke as a potential risk)
V20.31 - Birth -7 day/o
Summary of Pediatric ICD-9-CM Codes
| 789.00 | Abd pain/Colic |
| 706.1 | Acne |
| 079.0 | Adenovirus |
| 305.00 | Alcohol abuse |
| 287.0 | Allergic purpura (HSP) |
| 477.0 | Allergic rhinitis |
| 704.00 | Alopecia |
| 799.82 | ALTE |
| 626.0 | Amenorrhea |
| 041.84 | Anaerobes |
| 565.0 | Anal fissure |
| 285.9 | Anemia |
| 783.0 | Anorexia |
| 307.1 | Anorexia Nervosa |
| 300.00 | Anxiety |
| 786.03 | Apnea |
| 427.9 | Arrhythmia |
| 716.90 | Arthritis |
| 299.80 | Asperger Syndrome |
| 493.02 | Asthma, acute exacerbation |
| 493.00 | Asthma, stable |
| 493.01 | Asthma, status |
| 691.8 | Atopic dermatitis/Excema |
| 314.01 | ADD w/Hyperactivity |
| 314.00 | ADD w/o Hyperactivity |
| 388.45 | Auditory processing disorder |
| 299.00 | Autism |
| 279.49 | Autoimmune disease –
279.49 |
| 771.83 | Bacteremia, Newborn |
| 607.1 | Balanitis |
| V40.3 | Behavioral problems |
| 373.00 | Blepharitis |
| 368.8 | Blurred vision |
| 680.9 | Boil |
| 427.89 | Bradycardia |
| 779.81 | Bradycardia, newborn |
| 611.72 | Breast lump/mass |
| 466.11 | Bronchiolitis, RSV |
| 485 | Bronchopneumonia |
| 307.51 | Bulimia |
| 949.1 | Burn,1st degree |
| 949.2 | Burn, 2nd degree |
| 986 | CO inhalation: |
| E868.8 | Accidental |
| 709.09 | Cafe au lait spots |
| 112.0 | Candida, Oral (Thrush) |
| 771.7 | Candida, Newborn, Thrush |
| 112.3 | Candida, Skin |
| V02.59 | Carrier, Meningococcus, Other Bacterial Disease |
| V02.52 | Carrier, Strep, not Group B |
| 078.3 | Cat-scratch Disease |
| 682.9 | Cellulitis |
| 767.1 | Cephalohematoma, newborn |
| 380.4 | Cerumen, impacted |
| 373.2 | Chalazion |
| 786.50 | Chest pain |
| 052.9 | Chickenpox w/o Complications |
| 780.71 | Chronic Fatigue Syndrome |
| 789.7 | Colic |
| 558.3 | Colitis, allergic |
| 850.5 | Concussion w/LOC |
| 850.0 | Concussion w/o LOC |
| 312.0x | Conduct disorder, aggressive (bullying, stealing, defiance, lying) |
| 312.1x | Conduct disorder, unaggressive (tantrums, truancy) 5th digit: * 0 unspecified * 1 mild * 2 moderate * 3 severe |
| 312.81 | Conduct disorder, childhood onset |
| 312.82 | Conduct disorder, adolescent onset |
| 312.89 | Conduct disorder, other |
| 312.9 | Conduct disorder, unspecified (juvenile delinquency) |
| 255.2 | Congenital adrenal hyperplasia |
| 744.3 | Congenital ear anomaly, ear |
| 372.0 | Conjunctivitis,acute |
| 372.05 | Conjunctivitis allergic |
| 771.6 | Conjuntivitis/Dacryocystitis, newborn |
| 372.03 | Conjuntivitis, Purulent |
| 077.99 | Conjunctivitis, Viral |
| 564.09 | Constipation |
| 924.9 | Contusion |
| 918.1 | Corneal abrasion |
| 733.6 | Costochondritis |
| 786.2 | Cough |
| 079.2 | Coxsackievirus |
| 464.4 | Croup |
| 277.09 | Cystic Fibrosis w/ other sx |
| 595.0 | Cystitis |
| 690.18 | Dandruff |
| 276.5 | Dehydration |
| 783.42 | Delay in developmental milestones |
| 733.91 | Delayed bone age |
| 259.0 | Delayed puberty |
| 521.00 | Dental caries |
| 692.9 | Dermatitis, contact |
| 110.9 | Dermatophytosis, Ringworm |
| 311 | Depression |
| 250.01 | Diabetes Mellitus, Type 1 |
| 691.0 | Diaper rash |
| 787.91 | Diarrhea |
| 009.2 | Diarrhea, Infectious |
| 832.00 | Dislocation, elbow/Nursemaid's |
| 784.51 | Dysarthria (DELETE:
784.5) |
| 625.3 | Dysmenorrhea |
| 787.2 | Dysphagia |
| 041.4 | E. coli |
| 008.00 | E. Coli Enteritis, unspecified |
| 782.3 | Edema |
| 276.9 | Electrolyte imbalance |
| 049.9 | Encephalitis, Viral |
| 323.9 | Encephalitis, unspecified |
| 307.7 | Encopresis |
| 307.6 | Enuresis |
| 784.7 | Epistaxis |
| 381.81 | Eustachian tube dysfunction |
| 778.8 | Erythema Toxicum newborn |
| 530.81 | Esophageal reflux |
| 378.00 | Esotropia |
| 378.10 | Exotropia |
| 779.34 | Failure to thrive |
| 783.3 | Feeding problem |
| 779.31 | Feeding
problem, newborn (DELETE: 779.3) |
| 778.4 | Fever, Newborn |
| 780.6 | Fever of Unknown origin |
| 057.0 | Fifth Disease |
| 704.8 | Folliculitis |
| 005.9 | Food Poisoning |
| 930.1 | Foreign body, conjunctiva |
| 931 | F.B. ear |
| 933.1 | F.B. larynx |
| 932 | F.B. nose |
| 934.9 | F.B. respiratory |
| 919.7 | F.B. skin |
| 939.2 | F.B. vagina |
| 605 | Foreskin adhesions |
| 824.8 | Fx ankle |
| 810.00 | Fx, clavicle |
| 767.2 | Fx clavicle, newborn |
| 816.00 | Fx finger |
| 813.80 | Fx forearm |
| 813.45 | Fx radius |
| 813.46 |
|
| 813.47 | Fracture, Torus
(Buckle) fracture + radius |
| 826.0 | Fx toe |
| 814.00 | Fx wrist |
| 271.0 | G6PD Deficiency |
| 009.0 | Gastroenteritis |
| 558.9 | Gastroenteritis, acute |
| 009.0 | Gastroenteritis, infectious |
| 530.81 | Gastroesophageal reflux |
| V26.3 | Genetic counseling/Testing |
| 529.1 | Geographic tongue |
| 240.0 | Goiter |
| 041.85 | Gram-negative aerobes |
| 686.1 | Granuloma, umbilicus |
| 611.1 | Gynecomastia |
| 768.70 | HIE |
| V08 | HIV infection, no Sx |
| 795.71 | HIV Test, nonspecific results |
| 041.5 | H.influenzae |
| 784.9 | Halitosis |
| 074.3 | Hand, Foot, and Mouth Disease |
| 784.0 | Headache |
| 307.81 | Headaches-tension |
| 389.00 | Hearing loss |
| 389.05 | Hearing loss, Conductive, unilateral |
| 389.06 | Hearing loss, Conductive, bilateral |
| 389.20 | Hearing loss, Mixed |
| 389.21 | Hearing loss, Mixed, unilateral |
| 389.22 | Hearing loss, Mixed, bilateral |
| 389.13 | Hearing loss, Neurological |
| 389.17 | Hearing loss, Sensory |
| 705.1 | Heat rash |
| 041.86 | Helicobacter pylori |
| 228.01 | Hemangioma, skin |
| 578.0 | Hematemesis |
| 599.7 | Hematuria |
| 282.7 | Hemoglobinopathy |
| 786.3 | Hemoptysis |
| 070.9 | Hepatitis, unspecified |
| 571.49 | Hepatitis, chronic nonviral |
| 573.1 | Hepatitis w/ Inf Mono [w/075] |
| 789.1 | Hepatomegaly |
| 553.1 | Hernia, umbilical |
| 074.0 | Herpangina |
| 054.9 | Herpes Simplex |
| 053.9 | Herpes Zoster/Shingles |
| 054.2 | Herpetic Gingivostomatitis |
| 704.1 | Hirsutism |
| 784.42 | Hoarseness |
| 373.11 | Hordeolum (Stye) |
| 272.0 | Hypercholesterolemia |
| 780.8 | Hyperhidrosis/Excessive sweating |
| 272.4 | Hyperlipoproteinemia |
| 401.9 | Hypertension |
| 474.11 | Hypertrophy of tonsils |
| 474.10 | Hypertrophy of tonsils and adenoids |
| 300.7 | Hypochondriasis |
| 458.9 | Hypotension |
| 279.3 | Immunodeficiency, unspecified |
| 684 | Impetigo |
| 799.23 |
Impulsiveness |
| 075 | Infectious Mononucleosis |
| 487.1 | Influenza |
| 488.0 | Influenza due to Avian
Influenza virus |
| 488.1 | Influenza
due to novel H1N1 virus |
| 703.0 | Ingrown nail |
| 919.5 | Insect bite |
| 799.22 |
Irritability |
| 564.1 | Irritable bowel syndrome |
| 774.39 | Jaundice, newborn, breast-milk |
| 774.6 | Jaundice, newborm, physiologic |
| 446.1 | Kawasaki Ds/MCLS |
| 623.2 | Labial adhesion |
| 386.30 | Labyrinthitis |
| 872.00 | Laceration, ear |
| 870.1 | Laceration,eyelid |
| 873.43 | Laceration,lip |
| 873.60 | Laceration, mouth |
| 873.20 | Laceration, nose |
| 873.74 | Laceration,tongue |
| 271.3 | Lactase deficiency |
| 315.31 | Language developmental disorder |
| 464.00 | Laryngitis |
| 748.3 | Laryngomalacia, Tracheomalacia |
| 464.20 | Laryngotracheitis |
| 790.99 | Lead test/positive |
| 315.2 | Learning disorder |
| 719.70 | Limp |
| 289.3 | Lymphadenitis |
| 780.79 | Malaise and fatique |
| 263.9 | Malnutrition, unspecified |
| 578.1 | Melena |
| 047.9 | Meningitis,Viral |
| 320.9 | Meningitis, bacterial unspecified |
| 320.82 | Meningitis, Gram-negative |
| 754.53 | Metatarsus adductus |
| 346.00 | Migraine |
| 579.8 | Milk/formula intolerance |
| 625.2 | Mittelschmerz |
| 078.0 | Molluscum Contagiosum |
| 785.2 | Murmur, functional |
| 041.81 | Mycoplasma |
| 703.8 | Nail abnormalities/Onycholysis |
| 471.0 | Nasal polyps |
| 470 | Nasal septal deviation |
| 787.02 | Nausea |
| 799.21 | Nervousness |
| 288.0 | Neutropenia |
| 216.9 | Nevus |
| 832.2 | Nursemaid's elbow |
| 379.50 | Nystagmus |
| 259.9 | Obesity, endogenous |
| 278.01 | Obesity, morbid |
| 278.00 | Obesity, unspecified |
| V71.82 | Obs for susp. Antrax exp |
| V71.83 | Obs for susp Biologic agent exp |
| V71.89 | Obs for susp-meningitis/septicemia |
| V29.0 | Obs for susp inf, newborn |
| V71.2 | Obs for susp TB |
| 348.89 | Ondine’s Curse |
| 376.01 | Orbital cellulitis |
| 732.4 | Osgood-Schlatter |
| 388.70 | Otalgia |
| 380.10 | Otitis externa |
| 382.00 | Otitis media, acute |
| 382.01 | Otitis media, acute, w/ rupture |
| 382.3 | Otitis media, chronic |
| 381.10 | Otitis media, serous |
| 388.60 | Otorrhea |
| 785.1 | Palpitations |
| 300.01 | Panic attack |
| 681.02 | Paronychia, finger |
| 681.11 | Paronychia, toe |
| 132.1 | Pediculosis/Lice, Body |
| 132.0 | Pediculosis, Head |
| 754.82 | Pectus carinatum |
| 754.81 | Pectus excavatum |
| 384.20 | Perforated eardrum |
| 373.13 | Periorbital cellulitis |
| 475 | Peritonsillar abscess |
| 782.7 | Petechiae |
| 462 | Pharyngitis |
| 127.4 | Pinworm |
| 696.3 | Pityriasis Rosea |
| 041.2 | Pneumococcus |
| 788.42 | Polyuria |
| 521.8 | Poor dentition |
| 259.1 | Precocious puberty |
| 791.0 | Proteinuria |
| 593.6 | Proteinuria, postural |
| 041.7 | Pseudomonas |
| 374.30 | Ptosis |
| 312.33 | Pyromania |
| 782.1 | Rash |
| 493.90 | Reactive Airway Disease |
| 493.92 | Reactive Airway Disease, acute |
| 518.81 | Respiratory failure, acute |
| 752.52 | Retractile testis |
| 390 | Rheumatic Fever |
| 472.0 | Rhinitis, chronic |
| 079.3 | Rhinovirus |
| 058.10 | Roseola infection, unspecified |
| 058.11 | Roseola due to Herpes 6 |
| 058.12 | Roseola due to Herpes 7 |
| 008.61 | Rotavirus Enteritis |
| 133.0 | Scabies |
| 034.1 | Scarlet Fever/Scarlatina |
| 737.30 | Scoliosis |
| 608.89 | Scrotal/testicular mass |
| 706.3 | Seborrhea |
| 771.81 | Sepsis, newborn |
| 038.9 | Septicemia, unspecified |
| 785.59 | Shock, septic |
| 783.43 | Short stature |
| 786.05 | Shortness of breath |
| 461.9 | Sinusitis, acute |
| 473.9 | Sinusitis, chronic |
| 780.50 | Sleep disturbance |
| 782.2 | Skin mass/lump/nodule |
| 701.9 | Skin tag |
| 780.57 | Sleep apnea |
| 315.34 | Speech and language delay due to hearing loss |
| 784.59 | Speech disturbance,
other |
| 845.00 | Sprain/strain, ankle |
| 842.10 | Sprain/strain hand, finger |
| 847.0 | Sprain/strain neck |
| 842.00 | Sprain/strain wrist |
| 041.11 | Staphylococcus aureus |
| 378.9 | Strabismus |
| 041.01 | Streptococcus, Group A |
| 034.0 | Strep Throat |
| 786.1 | Stridor |
| 528.2 | Stomatitis |
| 438.14 | Stuttering |
| 692.71 | Sunburn |
| 757.6 | Supernumerary nipple |
| 380.12 | Swimmer's ear |
| 780.2 | Syncope/fainting |
| 795.5 | TB Test positive |
| 524.60 | TMJ |
| 785.0 | Tachycardia |
| 779.82 | Tachycardia, newborn |
| 786.06 | Tachypnea |
| 520.7 | Teething |
| 312.10 | Temper tantrums |
| 608.9 | Testicular pain |
| 307.20 | Tic disorder |
| 110.0 | Tinea capitis (Scalp) |
| 110.5 | Tinea corporis (Body) |
| 110.4 | Tinea Pedis (Feet) |
| 750.0 | Tongue tie |
| 463 | Tonsillitis, acute |
| 474.00 | Tonsillitis, chronic |
| 723.5 | Torticollis/Wry neck |
| 307.23 | Tourette Syndrome |
| 783.22 | Underweight |
| 598.80 | Urethritis, non-STD |
| 465.9 | URI |
| 788.41 | Urinary frequency |
| 708.9 | Urticaria, hives |
| 599.0 | UTI |
| 771.82 | UTI, newborn |
| 623.5 | Vaginal discharge |
| 989.5 | Venomous bite (bee,jellyfish,snake,spider,tic) |
| 057.9 | Viral Exanthem |
| 079.99 | Viral Infection, unspecified |
| 079.89 | Virus, Other Specified |
| 368.9 | Visual disturbance |
| 369.9 | Visual impairment |
| 709.01 | Vitiligo |
| 787.04 |
Vomiting |
| 536.2 | Vomiting, persistent |
| 779.32 | Vomiting, other |
| 779.32 | Vomiting, bilious |
| 078.19 | Warts, Plantar |
| 078.10 | Warts, Unspecified |
| 783.1 | Weight gain |
| 783.21 | Weight loss |
| 786.07 | Wheezing |
|
|
|
| V15.83 | Lapsed Immunization schedule |
| V18.0 | Family history of diabetes |
| V20.31 | Birth -7 day/o |
| V20.32 | 8 day/o to 28
day/o |
| V20.32 | Newborn Weight check |
| V30.00 | Liveborn, single |
| V30.01 | Liveborn, single, cesarean |
| V31.00 | Liveborn, twins |
| V31.01 | Liveborn, twins, cesarean |
| V64.00 | Vaccination not carried out, unspecified reason |
| V64.01 | Vaccination not carried out because of acute illness |
| V64.02 | Vaccination not carried out because of chronic illness or condition |
| V64.03 | Vaccination not carried out because of immune compromised state |
| V64.04 | Vaccination not carried out because of allergy to vaccine or component |
| V64.05 | Vaccination not carried out because of caregiver refusal |
| V64.06 | Vaccination not carried out because of patient refusal |
| V64.07 | Vaccination not carried out for religious reasons |
| V64.08 | Vaccination not carried out because patient had disease being vaccinated against |
| V64.09 |
Vaccination not carried out for other reason |
| V65.11 | Pre-birth visit
expectant parents |
| V71.4 | Observation after accident (incl. auto) |
| V71.3 | Obs after accident, work or school |
| V71.6 | Obs after assault |
| V29.8 | Obs for other susp cond, newborn |
| V71.89 | Obs for suspected condition [CF, DM, FB, Mening,suicide] |
| V71.2 | Obs for susp TB |
| V70.3 | Administrative exam for: adoption, camp, sports, school |
| V72.63 | Pre-op labs |
| V72.7 | Allergy testing |
| V65.3 | Diet management for specific conditions |
| V70.0 | Exam, not child |
| V20.2 | Infant/child health care |
| V72.84 | Preoperative exam |
|
|
| V07.1 | Allergy desensitization |
| V07.2 | Prophylactic immunotherapy |
| V06.1 | Vaccination-DaPT/DPT |
| V05.3 | Vacc. Hepatitis |
| V03.81 | Vacc. Hib |
| V04.8 | Vacc. Influenze |
| V06.4 | Vacc. MMR |
| V05.9 | Vacc. other single disease |
| V03.89 | Vacc. other specified bacteria |
| V03.82 | Vacc. pneumococcus |
| V06.5 | Vacc. Td/DT |
| V05.4 | Vacc. Varicella |
Pediatric immunization administration codes
Reportable under the following circumstances:
1) When the patient is under 8 years of age
And
2)
When the physician performs the vaccine-related counseling.
If both of these conditions are not met (eg, a 4-year old who receives vaccines
where the nurse does the counseling), physicians will be instructed to report
the appropriate existing immunization administration code(s) (CPT 90471-90474).
The codes are:
90465 Immunization administration under 8 years of age (includes
percutaneous, intradermal, subcutaneous, or intramuscular injections) when the
physician counsels the patient/family; first injection (single or combination
vaccine/toxoid), per day
(90465
should not be reported in conjunction with 90467)
90466 each additional injection (single or combination vaccine/toxoid),
per day (List separately in addition to code for primary procedure)
(Use 90466 in conjunction with 90465 or 90467)
90467 Immunization administration under age 8 years (includes intranasal
or oral routes of administration) when the physician counsels the
patient/family; first administration (single or combination vaccine/toxoid), per
day
(90467
should not be reported in conjunction with 90465)
90468 each additional administration (single or combination vaccine/toxoid),
per day (List separately in addition to code for primary procedure)
(Use
90468 in conjunction with 90465 or 90467)
These codes (90465-90468) are reported only when the
physician provides face-to-face counseling of the patient and family during the
administration of a vaccine. For
immunization administration of any vaccine that is not accompanied by
face-to-face physician counseling to the patient/family, report codes
90471-90474.
Telephone CPT Codes
(A direct link to the AAP
Payment for Telephone Care toolkit can be found at http://practice.aap.org/specialfeatures/telecarepmt.aspx.)
The AAP is pleased to announce that several new codes for non–face-to-face services (including telephone care and on-line medical services are now published in the 2008 Current Procedure Terminology (CPT®) manual. The good news will continue later this month when, the Centers for Medicare and Medicaid Services (CMS), publishes relative values units (RVUs) in the November 27, 2007 Federal Register.
The advent of new codes with relative values is the result of nearly 3 years of persistent advocacy by the AAP Section on Telephone Care (SOTC) and the Committee on Coding and Nomenclature (COCN) in partnership with other professional societies. While these developments represent an enormous step towards the goal of compensation for physician services by telephone, the approval of the codes and the assignment of RVUs does not ensure payment.
New CPT® Codes
These codes, include 3 time based codes for telephone care (99441, 99442, 99443) and 1 code for e-mail visits (99444). They will be available for reporting starting on January 1, 2008.
These major changes set the stage for physicians to secure payment for non-face-to-face services. But it will not be effortless. Practices will need to re-tool to implement these new codes and alert patients to the new billing policies. AAP chapters will need to educate payers through pediatric councils on the cost-effectiveness of non-face-to-face services. Pediatricians will need to bolster their negotiation and payer contracting skills. The Academy will provide resources to help along the way (see coming resources).
The time-based telephone codes replace the existing telephone care codes (99371-99373) in the case management section of the CPT manual and are to be used to report a telephone E/M service provided by a physician to an established patient, parent or guardian not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours.
Relative Values Assigned
After a national survey process in which many of you participated, the AMA/Specialty Society Relative Value Scale Update Committee (RUC) assigned RVUs to the non-face-to-face codes. Although the RVUs were not quite as high as had been anticipated, the assignment of RVUs to the telephone codes was a critical step towards ultimately securing payment for telephone care. In November, CMS published the codes and their RVUs in the Federal Register, although Medicare has classified them as “non-covered services.” The fact that these codes are not covered by the Medicare program is unfortunate, but not terribly problematic for pediatrics. Very few pediatric services are covered by Medicare, and in the past pediatricians have been successful getting paid for codes similarly classified, such as the preventive medicine service codes. The published RVUs represent an important benchmark as a starting point for negotiations with payers.
Unbundled Telephone Care
In
the past, payers were correct in claiming that all telephone calls from one
E/M visit until the next for a given patient were included in the
post-service descriptor. But this is no longer true. E/M codes’
current post-service descriptors state: that telephone care related to the
specific visit only is considered as part of the “post service.”
Specifically, post services care is to include “necessary
care coordination, telephonic or electronic communication assistance, and
other necessary management related to this office visit.”
The
key words, “related to this office visit” mean that telephone calls or
e-mails for a clinical problem not related to the previous E/M service
represent a new separately reportable medical encounter. The
non-face-to-face codes further specify that the telephone call or e-mail
visit do not originate
from a related assessment or management services provided within the
previous 7 days and nor leading to an assessment or management services in
the next 24 hours or soonest available appointment. Practices
will need to build in some screening questions and data searches to verify
that the non-face-to face encounter is a separately reportable service
before generating a bill.
E-Mail
Visits
The
other non-face-to-face CPT code may be used to report an on-line medical
evaluation (99444), provided by a physician to an established patient,
guardian or health care provider as long as it does not address a problem
originating from an E/M service provided within the previous 7 days.
Although an RVU was proposed, the assigned value for 2008 is 0. The
Academy hopes to try for a reasonable value in the future. Meanwhile,
physicians providing this service should report with the code, which
replaces the now-sunset Category III CPT code for this service (0074T). Some
insurers have already begun paying for e-mail visits.
United Health Care Developmental ScreeningIn response to reported denials by UHC for developmental screening, clarification was obtained from Richard Justman, MD, UHC National Medical Director. As part of the standard certificate of coverage, UHC Reimbursement policy is to pay separately for developmental screening (CPT code 96110). The UHC Reimbursement policy can be accessed here. UHC acknowledged that due to a systems error, denials were processed incorrectly for certain services. UHC is working to adjust claims that were incorrectly denied involving CPT code 96110 and there is no need for the physician to resubmit the claim. Below is the clarification provided by UHC: Good morning, Thank you for bringing this to my attention. No, our policy has not changed. However, we have identified a system error that has been incorrectly including certain cognitive services in other E/M codes. We have corrected this error going forward. We will also adjust claims that have been incorrectly paid without physician need to seek individual claim adjustments. I apologize for this error. Please let me know if you have questions.
Louis A. Terranova, MHA |