Coding and Compliance

(updated as of 9/29/2009)

Coding Questions?

AAP’s Division of Health Care Finance and Practice maintains a Coding Hotline. Members can email questions to aapcodinghotline@aap.org!

Multi-District Litigation Settlements

Settlements have been made with Aetna, CIGNA, Health Net, Prudential HealthCare, Anthem/WellPoint and Humana. Each settlement results in the health plans agreement to comply with most AMA CPT codes, guidelines and conventions. Note that if Georgia Law offers more protection than a particular settlement, then state law applies.

Review each multi-district litigation settlement on the plans physician website if it affects your practice (www.hmosettlements.com). The settlements are not all effective on the same date of service so review the plans websites frequently. If you think a plan is not compliant with its settlement, you may file a compliance dispute. The form is available at www.ama-assn.org/go/ settlements. Check the Georgia state laws.

Health Check Compliance

The Health Check program (Georgia’s preventive health care program for Medicaid and PeachCare for Kids) mandates that specific screening services be provided. Screening services include a comprehensive unclothed physical exam, a comprehensive health and developmental history, developmental assessment and screening, anticipatory guidance and health education, measurements, dental/oral health assessment, vision and hearing tests, laboratory procedures and lead and TB risk assessments/testing. All of the age appropriate components must be completed and documented for each screening visit performed and billed as per the Health Check Periodicity Schedule. All preventive services (with the exception of normal newborn care provided in the hospital) must be billed under the Health Check program. Click here for a summary of components required at Health Check Screens.

The Health Check Services Manual can be accessed at www.ghp.georgia.gov. Click on provider, then manuals, than Health Check Services. This document includes all of the requirements for performing and reporting Health Check services. This manual should be read in its entirety by all physicians, non physician providers and administrative staff. A current copy of the manual should be maintained in your office. See below for a list of just some of the vital information included in this manual.

Scope of services-see page 12

Reporting interperiodic hearing and vision services – see page 28

Lead screening – see page 22 and 32 and 44

TB screening – see page 48

Lead Testing – see Appendix A

Billing and Coding for Health Check services – see HIPAA referral codes on page 38, Appendix C, D, and E and Fee for Service Billing Tips on page 71

Some basic facts

Lead Testing:

Federal law requires that children enrolled in the Medicaid program must be tested for blood lead at 12 and 24 months of age.

The 12 month lead test may be performed from 9 to 15 months of age; the 24 month test may be performed from 18-35 months of age. Although there are ranges in the age requirements, the test should be performed as close as possible to 12 and 24 months of age. If a child has not been tested at the required age and they must be tested immediately when they are between 36 and 72 months old.
A lead risk assessment must be completed annually for all children between 36 and 72 months of age. A copy of the completed form must be maintained in the medical record. If the child is at high risk (1 or more “yes” answers or “I don’t know”), he or she must be tested for lead exposure. See pages 32-34 and Appendix A of the Health Check Services Manual for English, Spanish and Vietnamese forms and reporting procedures.
Health Check providers must report procedure code 36415 (venipuncture) or 36416 (capillary stick) with diagnosis code V82.5 when the child is referred to a Medicaid Laboratory or when the blood sample is obtained in their office. No payment is made for this service by the Medicaid program. See page 72 of the Health Check Services manual.
Physicians are strongly encouraged to use the Albany Regional Laboratory for blood lead level screens. See page 34 of the Health Check Services Manual for the address.

TB Risk Assessment:

The TB risk assessment must be performed at every Health Check visit. The form can be located on page 48 of the Health Check Services manual. A completed copy of the risk assessment must be maintained in the medical record.

See Appendix B for screening and testing requirements.

Interperiodic Health Check Screens:

Interperiodic Health Check screens are now covered services. Interperiodic Health Check screens can be provided when it is medically necessary to determine the existence of suspected physical or mental illnesses or conditions. They are allowed when a child requires a kindergarten, foster care, adoption or sports physical or when referred by a health, developmental or educational professional.

These do not replace the Health Check screens performed based on the periodicity schedule; rather they are for interperiodic screens. Documentation must specify what necessitates the interperiodic screening.

Important to remember - Interperiodic Health Check screens are not allowed if provided less than three (3) months from the date of a complete ‘periodic’ Health Check screen. All required components of Health Check must be performed when providing the interperiodic screen.

EPSDT Codes must be used also.

The Chapter has also developed a flow sheet for TB and Lead Risk assessments. This form can be adopted for use as part of your medical record to obtain the required information. Click here for the TB Form. Click Here for the Lead Risk Assessment Form.

2009 Code Updates

Partial list of new ICD-9 codes effective Oct. 1, 2009

279.41 Autoimmune lymphoproliferative syndrome

279.49 Autoimmune disease, not elsewhere classified

488.0 Influenza due to identified avian influenza virus

488.1 Influenza due to identified novel H1N1 influenza virus

756.72 Omphalocele

756.73 Gastroschisis

768.71 Mild hypoxic-ischemic encephalopathy

768.72 Moderate hypoxic-ischemic encephalopathy

768.73 Severe hypoxic-ischemic encephalopathy

779.31 Feeding problems in the newborn

779.32 Bilious vomiting in newborn

779.33 Other vomiting in newborn

779.34 Failure to thrive in newborn

784.42 Dysphonia

784.43 Hypernasality

784.44 Hyponasality

784.51 Dysarthria

784.59 Other speech disturbances

787.04 Bilious emesis

789.7 Colic

799.21 Nervousness

799.22 Irritability

799.23 Impulsiveness

799.24 Emotional lability

799.25 Demoralization and apathy

799.29 Other signs and symptoms involving emotional state

799.82 Apparent life-threatening event in infant

832.2 Nursemaid’s elbow

969.05 Poisoning by tricyclic antidepressants

969.09 Poisoning by other psychostimulants

969.71 Poisoning by caffeine

969.72 Poisoning by amphetamines

969.73 Poisoning by methylphenidate

995.24 Failed moderate sedation during procedure

V10.90 Personal history of unspecified type of malignant neoplasm

V15.06^ Allergy to insects and arachnids

V15.52 Personal history of traumatic brain injury

V15.80 Personal history of failed moderate sedation

V15.83 Personal history of underimmunized status

V15.86^ Personal history of contact with and (suspected) exposure

to lead

V20.31 Health supervision for newborn under 8 days

V20.32 Health supervision for newborn 8 to 28 days old

V60.81 Foster care (status)

V61.07 Family disruption due to death of family member

V61.08 Family disruption due to other extended absence of family

member

V61.23 Counseling for parent-biological child problem

V61.24 Counseling for parent-adopted child problem

V61.25 Counseling for parent (guardian)-foster child problem

V61.29^ Other parent-child problem

V61.42 Substance abuse in the family

V65.11^ Pediatric pre-birth visit for expectant parent(s)

^ = revised code

The following codes have been deleted:

239.8

274

279.4

348.8

453.8

768.7

779.3

784.5

799.2

969

969.7

E992

E993

E994

E995

E996

E998

V10.9

V53.5

V60.8

V72.6

V80.0

ICD-9 Codes

2010 CPT® Codes & Changes

(Coming December 2009)

Coding Tips

Preventive Medicine and Sick Visits:

If at the time of a preventive medicine visit, a significant amount of additional work or effort is required because of an abnormality, illness or problem an office visit may also be reported. When a preventive medicine visit and a problem oriented office visit are billed append modifier –25 (significant, separately identifiable evaluation and management service) to the “sick” visit code (99201-99215).

If the patient is a new patient, the appropriate level of service from codes 99381– 99385 and 99201-99205 may be reported. To report the new patient office/outpatient codes, three of the three key components (history, physical examination, medical decision making) must be performed and documented or time may be the controlling factor if over 50% of the total face to face time is spent in counseling and/or coordination of care. The preventive medicine visit includes an age appropriate physical examination; therefore, when selecting the level of service for the “sick” visit, typically only the level of history and medical decision making can be used. When only two of the three key components are met, the “sick” visit must be reported with the established patient codes 99212-99215 in association with the appropriate new patient code 99381-99385. If time is used as the controlling factor, the total time is based only the time devoted to the problem oriented visit.

Established patient visits would be reported using the age appropriate code 99391–99395 and 99212–99215 based on the performance and documentation of two of the three key components or time based on coding guidelines. The diagnosis code for the preventive medicine service should be V20.2. The problem oriented visit will be reported with the appropriate code for the documented condition, illness or problem.

Note when reporting Health Check services: The Health Check Services manual stipulates that only codes 99201, 99211 or 99212 may be reported on the same day of service as a Health Check. Check with your CMO regarding the policy. In addition, when a problem oriented visit is reported in association with a Health Check, both services are reported with the diagnosis code that describes the documented illness or problem. Also remember that the appropriate modifiers and condition/referral codes must be reported with the Health Check codes as required.

Do not report a "sick" visit with a preventive medicine or Health Check service if the problem is insignificant, would probably not have resulted in a scheduled sick visit, is incidental to the well visit or does not have any associated history, more extensive physical exam of the affected area(s) and plan/treatment for the illness/problem.

Documentation tip: Be sure to document the related history (CC, HPI, ROS, PFSH), physical exam and medical decision making related to the treatment and assessment of the illness or problem separately from the preventive medicine visit. If time is used in the selection of the “sick” visit code (99201-99215), make sure to document the total face to face time spent on the problem or abnormality, the total time spent counseling and a summary of the discussion.

Resources

AAP Pediatric Coding Newsletter™ - The American Academy of Pediatrics peer-reviewed coding and nomenclature newsletter. To subscribe to this valuable resource click here.

Medical Management Consultants

In response to your needs, we are currently building a file of consulting firms specializing in medical practice management, legal and tax & accounting for physicians. These firms have worked with pediatric practices providing various services. While we have researched these firms, we do not endorse or recommend any particular company. It will be the responsibility of each physician or practice to contact pediatrician references and perform due diligence before contracting with a consulting or legal firm. If you would like a copy of this list, please Click Here.

AAP Coding Hotline:

AAP’s Division of Health Care Finance and Practice maintains a FaxBack Coding Hotline. Members can call 1-800-433-9016, ext 4022. Leave your name and fax number. A form will be faxed to you for your questions and responses should return to you via fax within 1 week. You may also email your questions to aapcodinghotline@aap.org.

AAP Hassle Factor Form

Many practices have shared the difficulties providing quality care to children within a managed care setting. The American Academy of Pediatrics has developed the Hassle Factor Form, a managed care monitoring tool, which can be used to document problems as they occur.

AAP Members are now able to access the AAP Hassle Factor Form online.

Use this form to report health insurance administrative and processing concerns with specific health plans. The form has been revised to facilitate data entry and reporting with no need to download the form to complete it. The information submitted will be used to assist the AAP and the Georgia Chapter in identifying issues and facilitating public and private sector advocacy related to health plans.

Members can access the online Hassle Factor Form on the Member Center home page (www.aap.org) under More Resources. It can also be accessed on the private sector advocacy page (under private sector advocacy activities and resources pages) as well as the State Government Affairs page (under child health finance advocacy resources).

The online Hassle Factor Form is designed for data collection purposes and individual responses to each reported hassle will not be provided.

How will this form help? Specific examples strengthen your arguments. We may find that problems only occur in one region of the state or with one type of service. Alternately, we may find that a problem is statewide and pervasive. Either way, having a clearer understanding of the nature of the problem will increase our ability to be effective. But we need your help to make it work.

1. If unable to access the form on line, please download the Hassle Factor Form below and distribute them to all the appropriate individuals in your office or clinic.

2. Each time you encounter a problem, whether it is a first time or a recurring hassle with a specific managed care organization, please fill out a form online or if unable, fax a copy to the Chapter at (404) 249-9503.

3. The Chapter will compile this information and use it in our advocacy work with managed care organizations, the Medicaid department and other agencies.

We encourage you and your colleagues to use this tool. Speaking with one voice will help ensure that children receive the quality care they deserve. Click Here for the Hassle Factor Form

Internet Resources:
OIG Work Plan http://www.os.dhhs.gov/oig
Medicaid. https://www.ghp.georgia.gov/
American Academy of Pediatrics. http://www.aap.org/
CPT Documentation Guidelines, 1995 & 1997. www.cms.gov/physicians/
The American Medical Association. http://www.ama-assn.org/
Federal Register. http://www.access.gpo.gov/

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