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PEDIATRIC CPT® CODING

Materials by: Jacqueline J. Stack, CPC, CPC-I, CEDCPresented by: Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC

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CPT® Disclaimer CPT® copyright 2009 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related

components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

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Agenda• Newborn• Critical Care• Inpatient• Consultation• E/M• Preventive Care• Modifiers• Non Face-to-face• Common Procedures

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Newborn

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Attendance at Delivery

Attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn99464

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Standby Services/Resuscitation

• Delivery/birthing room resuscitation , provision of positive pressure violation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output– 99465

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Inpatient Neonatal and Pediatric Critical Care

• Initial inpatient neonatal critical care, per day, for the E/M of a critically ill neonate, 28 days of age or less– 99468

• Subsequent inpatient neonatal critical care, per day, for the E/M of a critically ill neonate, 28 days of age or less– 99469

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Inpatient Neonatal and Pediatric Critical Care

• Initial inpatient pediatric critical care, per day, for the E/M of a critically ill infant or young child, 29 days through 24 months of age– 99471

• Subsequent inpatient pediatric critical care, per day, for the E/M of a critically ill infant or young child, 29 days through 24 months of age– 99472

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Inpatient Neonatal and Pediatric Critical Care

• Initial inpatient pediatric critical care, per day, for the E/M of a critically ill infant or young child, 2 through 5 years of age– 99475

• Subsequent inpatient pediatric critical care, per day, for the E/M of a critically ill infant or young child, 2 through 5 years of age– 99476

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Intensive Care Services• Initial hospital care, per day, for the E/M of the neonate,

28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services– 99477

• Subsequent intensive care, per day, for the E/M of the recovering very low birth weight infant (present body weight less than 1500 grams)– 99478

• (present body weight of 1500-2500 grams)– 99479

• (present body weight of 2501-5000 grams)– 99480

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Pediatric Critical Care Patient Transport

• Critical care services delivered by a physician, face-to-face, during an inter facility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport– 99466

• Each addition 30 minutes– 99467

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Inpatient• Initial hospital care, per day, for the E/M of a patient– 99221 - 99223

• Subsequent hospital care, per day, for the E/M of a patient – 99231 - 99233

• Hospital discharge day management; 30 minutes or less– 99238

• More than 30 minutes– 99239

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Observation

• Initial observation care, per day, for the E/M of a patient– 99218 - 99220

• Observation care discharge day management– 99217

• Observation or inpatient hospital care, for the E/M of a patient including admission and discharge on the same date– 99234 – 99236

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Consultations

• Inpatient consultation for a new or established patient – 99251 - 99255

• Office consultation for a new or established patient– 99241 - 99245

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3 Rs of a Consult

• Request

• Rendered opinion

• Written Report

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Evaluation and Management

• New vs. established patients

• Office or other outpatient visit for the E/M of a new patient – 99201 - 99205

• Office or other outpatient visit for the E/M of an established patient– 99211 - 99215

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New vs. EstablishedExample:

A new provider joins your practice. He has been practicing in your area for some time. Some of his patients from the previous office that he worked at is now coming to your office. Are they considered new or established?

Example:You providers are covering for another provider in the hospital. The patient has since decided to switch to your practice. When they come in to our office for an appointment - lets say 4 months later - are they new or established?

Example:A newborn comes into the office. It is the first time the baby has been in your office. Is the baby new or established?

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E/M• Chief Complaint• History– History of Present Illness– Review of Systems– Past Medical, Social or Family History

• Exam– 95 vs. 97 guidelines

• Medical Decision Making– Number of diagnoses or management– Amount and/or complexity of data– Risk of complications

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Time

• Counseling and/or coordination of care

• Face to face time

• Floor/unit time

• Documentation

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Prolonged Services• Prolonged physician service in the office or other outpatient

setting requiring direct (face-to-face) patient contact beyond the usual service; first hour– 99354

• Each additional 30 minutes– 99355

• Prolonged physician service in the inpatient setting, requiring unit/floor time beyond the usual service; first hour– 99356

• Each additional 30 minutes– 99357

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Preventive Care• Initial comprehensive preventive medicine E/M 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, new patient– 99381 - 99387

• Periodic comprehensive preventive medicine, established patient– 99391 - 99397

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Modifier 25

Per CPT® Modifier 25 is Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

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Preventive Medicine Visit

• What does CPT® mean by: “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported.

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Five Questions

• Intent?

• Is it Minor?

• Will the Patient Return?

• Is the additional problem significant?

• Documentation?

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Preventive with E/MExample:

A six-year-old is seen for an age-appropriate established preventive medicine visit. Earlier in the day the child fell and injured his arm. The provider performs an X-ray and refers the patient to orthopedics.

Can this provider charge the preventive and an E/M on this same day?

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Preventive with E/M Example:

A 3-year-old is seen for an age-appropriate established preventive medicine visit. Seven days ago the patient was seen for an otitis media. The patient’s otitis media is resolved.

Can this provider charge the preventive and an E/M on this same day?

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Problems/Issues

• School Physicals

• Sport Physicals

• Driver License Physicals

• Work Physicals

• Frequency Limits

• No Coverage

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Vaccine Counseling

• Immunization administration younger than 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

• Each additional injection– 90466

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Vaccine Counseling

• Immunization administration younger than 8 years (includes intranasal or oral route of administration) when the physician counsels the patient/family; first administration (single or combination vaccine/toxoid), per day– 90467

• Each additional administration– 90468

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Vaccine Counseling

• Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)– 90471

• Each additional vaccine– 90472

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Vaccine Counseling

• Immunization administration by intranasal or oral route; one vaccine (single or combination vaccine/toxoid)– 90473

• Each additional vaccine– 90474

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Common Immunizations• Hepatitis A & B• Influenza • Human papilloma virus (HPV)• Pneumococcal• Rotavirus• Measles, mumps, and rubella• Diphtheria, tetanus and pertussis• Poliovirus• Varicella• Meningococcal

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Immunization • Proper Route/Oral vs. Injected• Proper Documentation– Route (site)– Amount– Lot Number– VIS – vaccine information sheet

• Age of Patient– Did Doctor do the counseling?

• Individual or combination vaccine• Number of Injections– 90472 Each Additional Vaccination

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Immunizations and Administration

Example:

A 16-year-old female is seen for her preventive visit and received HPV, meningococcal and tetanus, diphtheria and pertussis vaccines.

What administration codes are used with the vaccine codes?

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Immunizations and Administration

Example:A 2-month-old baby is seen for a well child check. The

baby also receives the 2 month immunizations. The baby receives a DtaP, HIB, IPV, Prevnar and Rotavirus.

How would you code these immunizations and administration?

With counseling, the vaccine administrations are coded with 90465, 90466 x 3, 90468. Without counseling, the vaccine administrations are coded with 90471, 90472 x 3,

90474.

Please note the code referenced in the audio is incorrect. The correct codes are provided on this slide.

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Screening Services

• Hearing screening, pure tone, air only test– 92551

• Vision screening, test of visual acuity, quantitative, bilateral– 99173

• Urinalysis– 81000 - 81003

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Development Tests

• Developmental testing; limited (eg. Developmental Screening Test II, Early Language Milestone Screen), with interpretation and report– 96110

• Extended (includes assessment of motor, language, social, adaptive and/or cognitive functioning by standardized developmental instruments) with interpretation and report– 96111

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Modifiers

24 - Unrelated E/M service by the same physician during a postoperative period

Example: Patient was seen three days ago for wound repair in

office. Today the patient is being seen for an upper respiratory infection.

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Modifiers52 Reduced Services

Example:

The provider is unable to complete a visit as planned due to the child’s disruptive behavior.

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Non Face-To-Face Physician Services

Telephone E/M service provided by a physician to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

– 99441

•11-20 minutes– 99442

•21-30 minutes– 99443

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On-Line Medical Evaluation

Online E/M service provided by a physician to an established patient, guardian, or health care provider not originating from a related E/M service provided within the previous 7 days, using the Internet or similar electronic communications network– 99444

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Non-Face-To-Face Nonphysician Services

• Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian not originating from a related assessment and management service provided within the previous 7 days nor leading to an assessment and management service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion– 98966

• 11-20 minutes of medical discussion– 98967

• 21-30 minutes of medical discussion– 98968

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On-Line Medical Evaluation

Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network98969

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Common Procedures

• Venipuncture (36400-36425)• Strep Tests (87880)• Cerumen Removal (69210)• Foreign Body Removal (69200, 30300)• Wart Removal/Lesions(11400-11440, 11600-

11646, 17000-17004)

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Common Procedures

• Simple Repair (12001-12021)• Intermediate Repair (12031-12057)• Complex Repair (13100-13160)• Circumcision/Penile Adhesions (54150-54163)• Aerosol Treatment (94644-94645)• Post Op 99024• Suture Removal

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References

• American Academy Of Pediatrics (2008). Coding for Pediatrics (13th ed.).

• American Medical Association (2009). CPT® Current Procedural Terminology (Professional Edition ed.).