Wiki Pediatric coding guidelines

[commitsvs]

Hello Guys,

Since I am new to pediatric coding, I require some clarification on the guidelines for pediatric coding.

1) Is there anyone who can suggest additional tests or screenings that the preventive medicine service for pediatrics can perform with age criteria?
2) Is there anyone who can help me understand the differences between CPT codes 96161/96160 and CPT code 96127?
3) Coding guidelines for billing CPT 96160, 99188, 96110, 96127, 99177, 92587, 99401, and 97802?
4) Is there any resources or documents/cheat sheet that can aid you in pediatric coding?
5) Is there someone who could provide me with MIPS guidelines for pediatric coding? Which MIPS coder should we bill and how much MIPS code should be billed?

I hope someone will help me understand.
Thank you,

 

[commitsvs]

1) In MDM, how do we consider unique tests in MDM? For example, our doctor orders Covid-19 with flu, CBC, urine culture, and urinalysis on the same day. Do we need to take into account that there are 3 or more distinct tests and documents for review? In addition, they have prescribed medication.

2)I have one more question about the number of complexity: 1 Acute illness with systemic symptoms.
Can we consider acute respiratory infection or acute pharyngitis with cough, fever, or nasal congestion as acute illness with systemic symptoms?

 

[rthomas@impcna.com]

Hello Guys,

Since I am new to pediatric coding, I require some clarification on the guidelines for pediatric coding.

1) Is there anyone who can suggest additional tests or screenings that the preventive medicine service for pediatrics can perform with age criteria?
2) Is there anyone who can help me understand the differences between CPT codes 96161/96160 and CPT code 96127?
3) Coding guidelines for billing CPT 96160, 99188, 96110, 96127, 99177, 92587, 99401, and 97802?
4) Is there any resources or documents/cheat sheet that can aid you in pediatric coding?
5) Is there someone who could provide me with MIPS guidelines for pediatric coding? Which MIPS coder should we bill and how much MIPS code should be billed?

I hope someone will help me understand.
Thank you,

Most of your payers follow the American Academy of Pediatrics Bight Futures Periodicity Schedule.

https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

 

[commitsvs]

Thank you, but insurance like Medicaid will not cover vision and hearing screening tests. Furthermore, there are many other screening tests that are not covered.

Can you give more give clarification on

1) In MDM, how do we consider unique tests in MDM? For example, our doctor orders Covid-19 with flu, CBC, urine culture, and urinalysis on the same day. Do we need to take into account that there are 3 or more distinct tests and documents for review? In addition, they have prescribed medication.

2) I have one more question about the number of complexity: 1 Acute illness with systemic symptoms.
Can we consider acute respiratory infection or acute pharyngitis with cough, fever, or nasal congestion as acute illness with systemic symptoms?

3) I am aware that counseling (CPT 99401) and nutrition therapy (97802) are not covered by Medicare. one more question Is there any scope for bill CPT 99401 and 97802 for insurance like Health First, Fidelis Care, and other commercial insurance?

Most of your payers follow the American Academy of Pediatrics Bight Futures Periodicity Schedule.

https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf

 

[rthomas@impcna.com]

Thank you, but insurance like Medicaid will not cover vision and hearing screening tests. Furthermore, there are many other screening tests that are not covered.

Can you give more give clarification on

1) In MDM, how do we consider unique tests in MDM? For example, our doctor orders Covid-19 with flu, CBC, urine culture, and urinalysis on the same day. Do we need to take into account that there are 3 or more distinct tests and documents for review? In addition, they have prescribed medication.

2) I have one more question about the number of complexity: 1 Acute illness with systemic symptoms.
Can we consider acute respiratory infection or acute pharyngitis with cough, fever, or nasal congestion as acute illness with systemic symptoms?

3) I am aware that counseling (CPT 99401) and nutrition therapy (97802) are not covered by Medicare. one more question Is there any scope for bill CPT 99401 and 97802 for insurance like Health First, Fidelis Care, and other commercial insurance?

You may want to double check with your state Medicaid guidelines. I am in Mississippi and our Medicaid does cover vision and hearing screens during a wellness at certain ages. We also have several insurance payers that will pay for them as well. Make sure you are using the appropriate CPT codes and modifiers if necessary.

1) Per AMA A unique test is defined by the CPT code set. When multiple results of the same unique test (e.g., serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. In your example you would have 5 unique tests unless the covid & flu are a combo test, ex: CPT 87428 (antigen detection by immunoassay, covid & flu type A & B)

2) Per AMA: An illness that causes systemic symptoms (symptoms affecting one or more organ systems) and has a high risk of morbidity without medical intervention.
For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or
to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general but may be a single system. Examples may
include pyelonephritis, pneumonitis, or colitis.

In our practice we consider URI or acute pharyngitis with cough, fever, or nasal congestion to be either a self-limited/minor problem or an acute, uncomplicated illness.

3) We do not see many children with Medicare. Since we are Internal Medicine & Pediatrics we do see a lot of adults with Medicare. Medicare utilizes G codes when it comes to counseling & nutrition therapy. I have been in pediatrics for about 15 yrs and majority of your insurances do not reimburse separately for counseling & nutrition therapy. Just about all of your major payers will have guidelines and coverage info regarding what can be done and paid separately during a wellness exam.

 

[commitsvs]

You may want to double check with your state Medicaid guidelines. I am in Mississippi and our Medicaid does cover vision and hearing screens during a wellness at certain ages. We also have several insurance payers that will pay for them as well. Make sure you are using the appropriate CPT codes and modifiers if necessary.

1) Per AMA A unique test is defined by the CPT code set. When multiple results of the same unique test (e.g., serial blood glucose values) are compared during an E/M service, count it as one unique test. Tests that have overlapping elements are not unique, even if they are identified with distinct CPT codes. In your example you would have 5 unique tests unless the covid & flu are a combo test, ex: CPT 87428 (antigen detection by immunoassay, covid & flu type A & B)

2) Per AMA: An illness that causes systemic symptoms (symptoms affecting one or more organ systems) and has a high risk of morbidity without medical intervention.
For systemic general symptoms such as fever, body aches or fatigue in a minor illness that may be treated to alleviate symptoms, shorten the course of illness or
to prevent complications, see the definitions for ‘self-limited or minor’ or ‘acute, uncomplicated.’ Systemic symptoms may not be general but may be a single system. Examples may
include pyelonephritis, pneumonitis, or colitis.

In our practice we consider URI or acute pharyngitis with cough, fever, or nasal congestion to be either a self-limited/minor problem or an acute, uncomplicated illness.

3) We do not see many children with Medicare. Since we are Internal Medicine & Pediatrics we do see a lot of adults with Medicare. Medicare utilizes G codes when it comes to counseling & nutrition therapy. I have been in pediatrics for about 15 yrs and majority of your insurances do not reimburse separately for counseling & nutrition therapy. Just about all of your major payers will have guidelines and coverage info regarding what can be done and paid separately during a wellness exam.

Thank you..