Optimal Clinical Coding for CYSHCN
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Overview
Though electronic medical records have simplified diagnostic coding for many,
understanding all available codes may support better billing and compensation,
particularly for services provided to children and youth with special health care
needs (CYSHCN). Some codes may not be recognized or compensated by some insurers,
but codes that are used appropriately are more likely to gain recognition and
compensation over time. In larger organizations, coding for all services rendered
may result in additional work relative value units (WRVU) credited to clinicians,
even if they do not result in third-party payment.
International Classification of Diseases (ICD-10) Coding
Diagnosis coding is based on the ICD-10-CM (International Classification of
Diseases, Tenth Revision, Clinical Modification), which includes codes that describe
diagnoses, conditions, signs, and symptoms. It also has codes for injuries,
poisoning, and other external causes of morbidity (such as accidents and exposures)
and factors influencing health status and contact with health services. The Centers
for Disease Control and Prevention (CDC) maintain an updated, free version of the
International Classification of Diseases, 10th Revision (WHO); ICD10Data.com offers a free, user-friendly way to search for
codes.
ICD-10 code books are organized in two ways—alphabetically by diagnosis (Index) and
numerically by code (Tabular List). In general, first look in the alphabetic list
for the diagnosis, symptom, etc. Then look up that code in the tabular list to
confirm its accuracy and to peruse subcodes and surrounding codes to ensure
appropriate specificity and level of detail.
The most specific code(s) possible should be used.
Example
Q20-28 Congenital malformations of the circulatory system
Q20-28 Congenital malformations of the circulatory system
- Q21 Congenital malformations of cardiac septa
- Q21.3 Tetralogy of Fallot
Example
H65-H75 Diseases of middle ear and mastoid
H65-H75 Diseases of middle ear and mastoid
- H66 Suppurative and unspecified otitis media
- H66.00 Acute suppurative otitis media without
spontaneous rupture of eardrum
- H66.004 Acute suppurative otitis media without spontaneous rupture of ear drum, recurrent, right ear
- H66.00 Acute suppurative otitis media without
spontaneous rupture of eardrum
ICD-10 Diagnostic Coding for Unknown Diagnoses
When a diagnosis is not known, 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."
Examples of presenting signs or symptoms or reason for the visit
include:
- Fever [R50.9]
- Hemoglobinuria [R82.3]
- Macrocephaly [Q75.3]
- Low-birth weight, 1500-1999 grams [P07.17]
- Routine child health check with abnormal findings [Z00.121]
- Fall from non-moving wheelchair, initial encounter [W05.0XXA]
ICD-10 Diagnostic Coding for Social Determinants of Health
Social determinants of health (SDOH) often impact the complexity of caring for
children and youth with special health care needs and increase the risk of
morbidity and mortality in those patients. With the 2021 guidelines for
office-based evaluation and management (E/M), presence of one or more SDOH that
result in greater risk may warrant coding for a higher level of E/M service (see
below under Current Procedural Terminology (CPT) Coding). Documenting the
presence and impact of the SDOH and using appropriate ICD-10 codes as secondary
is essential to support the higher service level. Many ICD-10 codes may be
relevant; below are some examples. [AAP: 2021]
(Table adapted from [AAP: 2021]. The table
does not include all potentially relevant SDOH; consult an ICD-10-CM manual or
ICD10Data.com for additional codes.)
Current Procedural Terminology (CPT) Coding
The codes used to bill for medical services are described by the
CPT (Current Procedural Terminology)
, published by the American Medical Association, and not available in a
free version. It includes various categories and types of codes, but we will focus
on Category 1 codes that are used for evaluation and management services in
outpatient settings. Most of the codes described below apply to services provided by
physicians. Some include services provided by other qualified health care
professionals, defined as “individuals who are qualified by education,
training, licensure/regulation (when applicable) and facility privileging (when
applicable) who perform professional services within his/her scope of practice and
independently reports that professional service.” This group includes nurse
practitioners, certified nurse specialists, physician assistants, clinical social
workers, physical therapists, and others. Some codes also include services provided
by clinical staff under the supervision of a physician or another qualified health
care professional.
Evaluation and Management Services
As of 2021, selection of evaluation and management (E/M) codes (99202-99205,
99212-99215, and 99XXX) is based on whether the patient is new or established
with the practice, and the complexity of medical decision making (MDM) or the
total time on the day of the encounter. 99211 remains available for visits that
do not require physician presence, such as RN visits, specimen collection,
etc.
Encounter time, specified in distinct ranges that vary by new or
established patient, now includes now includes nonface-to-face work on the day
of the encounter and may apply whether or not counseling/coordination of care
predominated during the visit. Activities that may contribute to the
time-related coding include:
- Reviewing tests in visit preparation
- Counseling or educating a patient, family, or caregiver (including prolonged discussion related to misperceptions, information gathered from the internet, etc.)
- Reporting test results by phone
- Ordering medications, tests, or procedures
- Documenting related work at home
Time increments are:
The elements of MDM that contribute to it being straightforward, low,
moderate, or high complexity include:
- The number and complexity of problems addressed; it is no longer necessary to document all of a patient’s diagnoses, just those addressed during the encounter
- The amount and complexity of data reviewed and analyzed; it is no longer necessary to include irrelevant data in the encounter record
- Risk of complications or morbidity, including social determinants of health and reasons behind decisions to not intervene in some way
For detailed guidelines on selection of E/M codes by MDM or time, see
CPT Evaluation and Management (E/M) Office or Other Outpatient and Prolonged Services Code and Guideline Changes (AMA).
When preventive medicine services (“well-child visits”) for CYSHCN
significantly exceed the usual service provided for such a visit, an office
visit code with a -25 modifier may be added. For example,
billing a preventive medicine visit code (99381-99397) plus an office visit code
with the modifier (e.g., 99213-25 or 99214-25) would account for the added
service addressing the child’s spasticity, seizure disorder, and feeding
problems.
The AAP offers more information at Coding at the AAP
and in their Coding Fact Sheets (AAP) with detailed
information on topics such as:
-
Adolescent Confidentiality Related to Billing (AAP) (
615 KB)
-
Adolescent Health Services Coding (AAP) ( 79 KB)
-
After-hours and Special Services Coding (AAP) ( 84 KB) (urgent
and when not regularly scheduled)
-
Coding for Pediatric Preventive Care (AAP) ( 2.0 MB)
-
Oral Health Coding (AAP) ( 223 KB)
- Osteopathic Manipulation Coding (AAP)
-
Coding for Telemedicine Services (AAP) ( 245 KB)
-
Transition to Adult Health Care Coding - 2021 (AAP & GotTransition) ( 426 KB)
- Various mental health/behavioral issues, including
ADHD Coding (AAP) ( 149 KB) and Anxiety Coding (AAP) ( 148 KB)
Guidelines for documentation (and everything else related to Medicare
and Medicaid billing) can be found on the Center for Medicare & Medicaid
Services (CMS) website at CMS Online Manual System.
The Physician Fee Schedule Look-Up Tool (CMS)
offers information on each CPT (aka Healthcare Common Procedure Coding System,
HCPCS) code, including assigned relative value units (RVUs), Medicare payment
amounts (both national and by specific localities), and more. Acceptance of
codes and payment by Medicaid and commercial insurance plans will vary by state
and other factors.
Medical Home Services
Over the past few years, CPT has added codes for several special
services provided by Medical Homes, including non-face-to-face services, home
visits, care plan oversight, team conferences, transition to adult care
management, and complex chronic care management. Deciding whether to
use new codes (and some older codes, such as telephone services)
is complicated by questions about their acceptance or compensation by a
practice’s range of payers and the potential consequences for patients/families,
including triggering unexpected co-payments or full payment for those with high
deductibles. Over time, most codes accepted by Medicare are accepted by other
payors, which may take longer if the codes are rarely submitted. Those
considerations, along with discussions with key payers and patients’ parents,
should drive development of a thoughtful strategy for supporting the provision
of services for CYSHCN. Informing parents prior to use of codes for which
insurance coverage is not certain can avoid unwelcome surprises and angry
reactions if a billed code is rejected.
2022 Coding and Payment Tip Sheet for Transition from Pediatric to Adult Health Care ( 509 KB)
from Got Transition (MCHB/NAAAH)
provides an excellent overview of the CPT codes relevant to outpatient
care of CYSHCN. It also offers detailed descriptions of the codes
and their associated RVUs and Medicare payment amounts. Though the document was
prepared to support clinicians transitioning patients and includes
transition-specific scenarios, the codes and their descriptions/payments apply
to all ages. Before using any unfamiliar codes discussed below, we suggest
consulting the
CPT (Current Procedural Terminology)
or a Certified Coding Specialist to
ensure detailed compliance.
509 KB)
from Got Transition (MCHB/NAAAH)
provides an excellent overview of the CPT codes relevant to outpatient
care of CYSHCN. It also offers detailed descriptions of the codes
and their associated RVUs and Medicare payment amounts. Though the document was
prepared to support clinicians transitioning patients and includes
transition-specific scenarios, the codes and their descriptions/payments apply
to all ages. Before using any unfamiliar codes discussed below, we suggest
consulting the
CPT (Current Procedural Terminology)
or a Certified Coding Specialist to
ensure detailed compliance.
Care Plan Oversight Services
These apply to physician supervision of a patient (who is not present
during the service) in a home, domiciliary, or rest home requiring complex and
multi-disciplinary care involving regular physician development/revision of care
plans, review of status reports and related laboratory and other studies,
communication with relevant other providers, family members, surrogate
decision-makers, and/or caregivers, and integration of new information into the
care plan or adjustment of medical therapy.
- The appropriate code is based on total time within a calendar month: 99339 (15-29 minutes) or 99340 (30 minutes or more).
Home Services
These apply to E/M services provided in a private residence, temporary
lodging, or short-term accommodation. The CPT codes, like those for E/M
services, are based on new vs. established patient and the components of care
provided. “Typical” visit durations are suggested, allowing time-based coding
when care coordination/counseling comprise more than 50% of the visit time. The
codes include:
- For new patients, 99341-99345, with typical duration from 20 to 75 minutes
- For established patients, 99347-99350, with typical duration from 15 to 60 minutes
These codes are not included in Transition to Adult Health Care Coding - 2021 (AAP & GotTransition) ( 426 KB), mentioned above.
426 KB), mentioned above.
Prolonged Services With Direct Patient Contact
These CPT codes are used, separately and in addition to the primary E/M code, when
prolonged services involving direct patient contact are provided by a physician
or other qualified health care professional for at least 30 minutes beyond the
typical time for the primary service. As of 2021, these codes can no longer be
used with office visit codes (99202-99215). The codes report the total duration
of face-to-face time spent on a given date providing prolonged service, even if
that service is not continuous.
- 99354 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
- 99355 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.
Prolonged Services Without Direct Patient Contact
These are used to report prolonged, non-face-to-face services related to a recent
or upcoming E/M service but not provided as part of that service/visit. As of
2021, these codes can no longer be used with office visit codes (99202-99215).
The services must be performed by the billing clinician on a single day, but the
time spent need not be continuous. Such services might include review of
records, writing a summary or report, etc.
- 99358 is used for the first “hour” (30-74 minutes) of prolonged services; this code may be used only once for a given date.
- 99359 is used for each additional 30 minutes beyond the first hour (total of 75-104 minutes, 105-134 minutes, etc.) on a given date.
Prolonged service codes are reported for time spent by the billing
clinician only, not for clinical staff. They cannot be used for time spent
related to services for which no typical time is specified, nor can they be
reported during the same service period as complex chronic care management (CCM)
services or transitional care management (TCM) services. Prolonged Services Codes: Criteria for Use (AAP) offers further
explanation, tips, and vignettes.
Prolonged Clinical Staff Services With Physician or Other Qualified Health Care Professional Supervision
These are reported, in addition to the designated E/M service, when a prolonged
E/M service is provided that involves prolonged clinical staff face-to-face time
beyond that typical for the service while the physician or qualified health care
professional is present to provide direct supervision. The time reported is the
total duration spent by clinical staff on the date of the designated E/M
service. These codes may be reported for no more than two simultaneous patients.
- 99415 is used for the first hour of prolonged clinical staff service
- 99416 is used for each additional 30 minutes beyond the first hour
COVID-19 Vaccine and Administration Services
See Coding During the COVID-19 Public Health Emergency (AAP) ( 401 KB) for more
detail.
401 KB) for more
detail.
COVID-19 Testing
See COVID-19 Update, Oct. 2020 (AMA) () or
Coding During the COVID-19 Public Health Emergency (AAP) ( 401 KB) for more
detail
) or
Coding During the COVID-19 Public Health Emergency (AAP) ( 401 KB) for more
detail
Medical Team Conferences
These are used for face-to-face participation of 3 or more qualified health care
professionals from different specialties/disciplines who are providing care to
the patient, with or without the presence of the patient, family members,
surrogate decision-makers, or community agencies. Reporting clinicians must have
provided face-to-face services to the patient in the previous 60 days. The time
reported includes only the time spent discussing the patient and not record
keeping or report generation.
- 99366 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient and/or family present.
- 99367 is used by physicians for participation in conferences of 30 minutes or more, with the patient or family not present. (Physicians should use E/M codes to report time in team conferences with the patient and/or family present.)
- 99368 is used by nonphysician qualified health care professionals for participation in conferences of 30 minutes or more, with patient or family not present.
General Behavioral Health Integration Care Management
99484 is used by the supervising physician or other
qualified health care professional to report care management services
(face-to-face or non-face-to-face) performed by clinical
staff for a patient with a behavioral health/substance use
condition. The reported service must have required 20 minutes or more in a
calendar month, and a treatment plan is required. The reporting professional
must have an ongoing relationship with the patient.
Care Management Services
These are used for management and support services provided by a physician or
other qualified health care professional or by clinical staff under the
professional’s direction to a patient residing at home or in a domiciliary, rest
home, or assisted living facility and who has 2 or more chronic or episodic
conditions expected to last 12 months or longer and that place the patient at
significant risk of death, acute exacerbation/decomposition or functional
decline. Services include those related to developing and managing a care plan,
coordinating care of other professionals or agencies, and educating
patients/families about the condition. A comprehensive care plan must be
documented and shared with the patient and/or caregiver, identify individuals
responsible for each intervention, and include requirement for periodic review
and, if needed, revision of the plan.
- 99487 is used for establishment/substantial revision of a comprehensive care plan involving moderate-high complexity medical decision-making requiring 60 minutes of clinical staff time in a calendar month
- 99489 is used to report each additional 30 minutes required in a calendar month
- 99490 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 20 minutes of clinical staff time in a calendar month
- 99491 is used for establishment, implementation, revision, or monitoring of a comprehensive care plan requiring at least 30 minutes of physician or other qualified health care professional time in a calendar month
The time reported for 99487, 99489, and 99490 includes face‐to‐face
and non‐face‐to‐face time spent by clinical staff in communicating with the
patient and/or family, caregivers, other professionals, and agencies; creating,
revising, documenting, and implementing the care plan; or teaching
self‐management during the month. Because the reporting requirements are
complex, we recommend reviewing them in detail or consulting a coding
specialist.
Principal Care Management (PCM) Services
Using these codes, practices may bill for chronic care management
(CCM) services provided to patients with one serious chronic condition. These
codes may not be used simultaneously for the same patient with other care
management services. Conditions must include these elements: with the following
elements: one complex chronic condition lasting at least three months, which is
the focus of the care plan; the condition is of sufficient severity to place the
patient at risk of hospitalization or to have been the cause of a recent
hospitalization; the condition requires development or revision of a
disease-specific care plan; the condition requires frequent adjustments in the
medication regimen; and/or the management of the condition is unusually complex
due to comorbidities.
- G2064. CCM for a single high-risk disease (i.e., PCM) at least 30 minutes of physician or other qualified health care professional time per calendar month
- G2065. CCM for a single high-risk disease, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional per calendar month
Transitional Care Management Services
These are services for new or established patients whose medical
and/or psychosocial problems require moderate or high complexity medical
decision-making during transition from an inpatient or other facility-based care
setting to the patient’s home, domiciliary, rest home, or assisted living
setting. The service period comprises the 29 days beginning on the date of
discharge. Services include initial contact, a face-to-face visit, and
medication reconciliation in combination with non-face-to-face services provided
by the physician, other qualified health care professional, and/or licensed
clinical staff under the professional’s direction.
- 99495 includes communication (direct contact, telephone, electronic) with the patient/caregiver within 2 business days and a face‐to‐face visit within 14 calendar days of discharge and medical decision‐making of at least moderate complexity
- 99496 includes communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days, a face‐to‐face visit within 7 calendar days of discharge, and medical decision‐making of high complexity
Because the reporting requirements are complex, we recommend reviewing
them in detail or consulting a coding specialist.
Telephone Services
These comprise non-face-to-face E/M services provided by a physician
or other qualified health care professional by phone to an established patient
or their guardian and that are not related to an E/M service provided within the
previous 7 days and do not lead to such a service within 24 hours or the soonest
available appointment.
- 99441 involves 5-10 minutes of medical discussion
- 99442 involves 11-20 minutes of medical discussion
- 99443 involves 21-30 minutes of medical discussion
Online Medical Evaluation
- 99421. Online digital E/M service, for an established patient, 5-10 minutes cumulative time over up to seven days
- 99422. Online digital E/M service, for an established patient, 11-20 minutes cumulative time over up to seven days
- 99423. Online digital E/M service, for an established patient, 21 or more minutes cumulative time over up to seven days
Interprofessional Telephone/Internet/Electronic Health Record Consultations
These are assessment and management services provided by a
consultative physician to the patient’s treating/requesting physician or other
qualified health care professional via telephone, the internet, or electronic
health record and include a verbal and written report.
- 99446 involves 5-10 minutes of medical consultative discussion and review
- 99447 involves 11-20 minutes of medical consultative discussion and review
- 99448 involves 21-30 minutes of medical consultative discussion and review
- 99449 involves 31 minutes or more of medical consultative discussion and review
Education and Training for Patient Self-Management
These codes are used by nonphysician qualified health care
professionals for provision of prescribed education and training for patient
self-management using a standard curriculum, face-to-face with the patient
and/or caregiver/family. Codes are used for each 30 minutes with:
- 98960 – an individual patient
- 98961 – 2-4 patients
- 98962 – 5-8 patients
Resources
Information & Support
Related Portal pages:
For Professionals
Medical Home Resources (AAP)
An in-depth look at the medical home model and how to implement it. Includes information about quality improvement, maintenance
of certification activities to improve your medical home, and financing and payment resources; American Academy of Pediatrics.
Coding Resources (AAP)
Books, quick references, and how-to guides for CPT and ICD-10 coding specific to pediatrics; available for purchase from the
American Academy of Pediatrics.
2022 Coding and Payment Tip Sheet for Transition from Pediatric to Adult Health Care ( 509 KB)
Thirty-two page booklet of CPT coding options for the provision of transition-related services; from Got Transition and the
American Academy of Pediatrics.
CPT (Current Procedural Terminology)
Link to the American Medical Association Store where the current version of the CPT can be purchased in hardcopy.
ICD10Data.com
Free, user-friendly reference website that contains all of the official American ICD-10-CM (diagnosis) and ICD-10-PCS (procedure)
medical billing codes.
Physician Fee Schedule Look-Up Tool (CMS)
Offers information on each CPT (aka Healthcare Common Procedure Coding System, HCPCS) code, including assigned relative value
units (RVUs), payment amounts (both national and by specific localities) and more; from the Centers for Medicare and Medicaid
Services (CMS)
Page Bibliography
AAP Division of Health Care Finance.
Use ICD-10-CM codes when social determinant of health identified.
American Academy of Pediatrics; (2021)
https://www.aappublications.org/news/2021/01/01/coding010121. Accessed on 1/21/2021.