Optimal Coding

Accurate coding for procedures, with Current Procedural Terminology (CPT) codes [American: 2006], and for diagnoses, with International Classification of Diseases - 9th Revision - Clinical Modification (ICD-9-CM) codes [ICD-9-CM: 2006], are important for data collection and billing for services in medical practices. Annual updates of CPT are published by the American Medical Association (AMA) www.AMABookstore.com, and available from the AAP Bookstore www.aap.org/bookstore, and elsewhere.

Often, services provided to children with special health care needs (CSHCN) exceed the typical services provided to most patients in primary care settings, and most of these are described by existing CPT codes. However, they are used much less frequently than the more common codes and some insurers do not recognize or reimburse for these codes appropriately. Similarly, the diagnoses of many CSHCN are uncommon, or rare, and may not be specifically described in ICD-9-CM or, if they are, the codes may not be readily recognized by our billing/coding personnel or by insurers. Nevertheless, detailed, accurate, and complete coding provides the best available methodology to communicate to insurers and other administrative agencies the nature of the patients we treat and the services we provide. Codes that are used appropriately are more likely to gain recognition and reimbursement than codes that are never used. The following are examples of CPT codes for services that are expected to be provided within Medical Homes but that are often not coded for correctly or compensated properly:

• Hearing screening, pure tone (92551),
• Central Nervous System Assessments (developmental testing) (96110-96111), see the Developmental Testing Coding Fact Sheet,
• Services after hours, emergency, etc. (99050-99058),
• Special Reports (99080),
• Collect/interpret physiologic data, ≥30 min. (99091),
• Vision screening, quantitative, bilateral (99173),
• Care plan oversight services, home (99339-99340),
• Home visits (99341-99350),
• Prolonged physician services, face-to-face (99354-99357),
• Prolonged physician services, not face-to-face (99358-99359),
• Team conferences (99361-99362),
• Telephone calls (99371-99373),
• Care plan oversight services, home health (99374-99375),
• Care plan oversight services, hospice (99377-99378),
• Care plan oversight services, nursing facility (99379-99380),
• Counseling and/or risk factor reduction intervention codes for individuals (99401-99404) or for groups (99411-99412),
• -25 modifier, used when the service significantly exceeds the usual service provided for that code (e.g., billing a preventive medicine visit code, 99381-99397, plus a 99214-25 for the added time dealing with the child's spasticity, seizure disorder, and feeding problems).

Appropriate documentation is always important to support the kinds and levels of service billed. For the codes listed above, many payers will require that documentation be submitted with each request for payment. The guidelines for documentation for Evaluation and Management codes have been promulgated by Medicare and the AMA (Documentation Guidelines for Evaluation and Management Services. American Medical Association and Health Care Financing Administration, May 1997). These can be found in the Medicare Compliance Manual published by the AMA and updated periodically or downloaded from the Center for Medicare and Medicaid Services web site Medicare Learning Network or from our site - click Documentation Guidelines ( 130 KB) .

These guidelines are complex and lengthy. We have tried to summarize them in a short and more manageable format - see CPT Documentation Guide in the Tools below for a one-page chart summarizing these documentation criteria for office Evaluation and Management (E&M) codes.

Diagnosis coding is based on the ICD-9-CM, available through the AMA www.AMABookstore.com, the AAP Bookstore www.aap.org/bookstore, and others. The ICD-9-CM includes codes that describe diagnoses, conditions, signs, and symptoms. Also included in the ICD-9 (for short) are codes for poisoning and external causes of adverse effects of drugs and other chemical substances (E codes), and a supplementary classification of factors influencing health status and contact with health services (V codes). The latter will have considerable relevance for services provided to children with special health care needs. A Online ICD9 is available.

Each code will have a minimum of three numerals (V codes have a V and two numerals; E codes have an E and three numerals), most with an additional digit or two following a decimal point, for example "Down syndrome" is coded by 758.0, whereas "other conditions due to sex chromosome abnormalities" is coded by 758.81.

The most specific code(s) possible should be used, for example, in the table below of a category of congenital heart disease, a "complete transposition of the great vessels" requires two digits following the decimal point to most specifically describe it.

• 745 Bulbus cordis anomalies and anomalies of cardiac septal closure
  • 745.0 Common truncus
  • 745.1 Transposition of great vessels
    • 745.10 Complete transposition of great vessels
    • 745.11 Double outlet right ventricle
    • 745.12 Corrected transposition of great vessels
    • 745.19 Other
  • 745.2 Tetralogy of Fallot
  • 745.3 Common ventricle
  • 745.4 Ventricular septal defect
  • 745.5 Ostium secundum type atrial septal defect
  • 745.6 Endocardial cushion defects
    • 745.60 Endocardial cushion defect, unspecified type
    • 745.61 Ostium primum defect
    • 745.69 Other
  • 745.7 Cor biloculare
  • 745.8 Other
  • 745.9 Unspecified defect of septal closure

When a diagnosis is not known, the presenting signs or symptoms may be the most accurate way to describe the reason for providing the service. Codes should not be used for conditions to be "ruled out" or that are "possible" or "probable"; rather the presenting signs or symptoms or reason for the visit (e.g., fever [780.6]; hemoglobinuria [791.2]; macrocephaly [742.4]; low birth weight, 1500-1999 grams [V21.34]; routine child health check [V20.2]; fall from an escalator [E880.0]; etc.) should be used.

The codes are organized in two ways: first alphabetically by diagnosis and second numerically by code (tabular list). In general, when looking up a diagnosis, you should first look in the alphabetic list for the diagnosis, symptom, etc., and then look up that code in the tabular section to confirm its accuracy and to peruse subcodes and surrounding codes to assure it specificity and level of detail.