AAP Pediatric Coding Newsletter · 2020-02-06 · For specific coding questions, contact the AAP...

November 2019 | Volume 15 | Number 2coding.aap.org

Chronic Care Management: Current Coding Options

Subspecialty Coding: CPT ® 2020—Long-term Electroencephalogram Codes

You Code It! Neonatal Critical Care

Coding Hotline

You Code It! Answers: Neonatal Critical Care

Do You Have the Coding Resources You Need for 2020?

AAP Updates Policy on Pediatric Application of Coding, Valuation Systems

AAP Pediatric Coding Newsletter™ Quiz

AAP Pediatric Coding Newsletter™

Proven coding guidance from the American Academy of Pediatrics

2 | AAP Pediatric Coding Newsletter™ | http://coding.aap.org | November 2019

AAP Pediatric Coding Newsletter™ Volume 15, Number 2, ISSN 1934-5135 (Print), ISSN 1934-5143 (Online) is published monthly by the American Academy of Pediatrics, 345 Park Blvd, Itasca, IL 60143. © 2019 American Academy of Pediatrics. All rights reserved. Periodicals postage paid at Arlington Heights, IL, and additional entries.

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Vignettes are provided to illustrate correct coding applications and are not intended to offer advice on the practice of medicine.

CONSULTING EDITORCindy Hughes, CPC, CFPC

STAFF EDITORSBecky Dolan, MPH, CPC, CPEDCTeri Salus, MPA, CPC, CPEDCLinda Walsh, MAB

EDITORIAL BOARDLinda D. Parsi, MD, MBA, CPEDC, EditorVita Boyar, MDJoel F. Bradley, MDRyan Cantville, DODavid M. Kanter, MD, MBA, CPCS. Kalyan Katakam, MD, MPHSteven E. Krug, MDJamie C. Lago, MD, CPCEdward A. Liechty, MDJeffrey F. Linzer Sr, MDJeanne Marconi, MDRichard A. Molteni, MDJulia M. Pillsbury, DORenee F. Slade, MDSanjeev Y. Tuli, MD

AMERICAN ACADEMY OF PEDIATRICS PUBLISHING STAFFMary Lou White Chief Product and Services Officer/SVP, Membership, Marketing, and PublishingMark Grimes Vice President, Publishing Laura Underhile Editor, Professional/Clinical PublishingJason Crase Manager, Editorial ServicesLeesa Levin-Doroba Production Manager, Practice ManagementPeg Mulcahy Manager, Art Direction and ProductionMaryjo Reynolds Marketing Manager, Practice Publications

Proven coding guidance from the American Academy of Pediatrics

CONTENTS3 Chronic Care Management: Current Coding

Options

5 Subspecialty Coding: CPT ® 2020—Long-term Electroencephalogram Codes

7 You Code It! Neonatal Critical Care

8 Coding Hotline

9 You Code It! Answers: Neonatal Critical Care

10 Do You Have the Coding Resources You Need for 2020?

11 AAP Updates Policy on Pediatric Application of Coding, Valuation Systems

12 AAP Pediatric Coding Newsletter™ Quiz

AAP PediatricCoding Newsletter™

Coding Symbols ▲ Revised code• New code+ Add-on codeL Product pending US Food and Drug Administration approval# Out-of-numerical-sequence code★ Telemedicine

AAP Pediatric Coding Newsletter™ | http://coding.aap.org | November 2019 | 3

...continued on page 4

Chronic Care Management: Current Coding OptionsChronic care management (CCM) codes provide an opportunity to report time spent between face-to-face visits managing the care of patients with 2 or more chronic conditions.

There have been significant changes to CCM codes since the original complex CCM codes (99487–99489) were introduced in 2013. Code 99488 was subsequently deleted. Codes 99490 and 99491 were added to allow reporting of CCM services with lower time and complexity thresholds. Current codes for reporting CCM services and examples are shown in Table 1.

With 3 different levels of CCM services and 4 potential codes, it is helpful to review the similarities and differences in the services represented by CCM codes.

SimilaritiesAll CCM services require the following:

• Patients must have 2 or more chronic continuous or episodic health conditions that are expected to last at least 12 months, or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

Examples of comorbid conditions that may require CCM include sickle cell disease with asthma, autism spectrum disorder and epilepsy, cerebral palsy with attention-deficit/hyperactivity disorder, hemiparesis due to stroke in infancy, post-cardiac transplant with long-term immunosuppression, and developmental delay.

• Only a single physician or other qualified health care professional (QHP) reports CCM services for providing or overseeing the management and/or coordination of services, as needed, for all medical conditions, psychosocial needs, and activities of daily living.

More than one physician or other QHP may manage multiple chronic conditions, but only one physician or QHP who accepts primary responsibility for the patient’s overall care may report CCM services.

• A care plan based on a physical, mental, cognitive, social, functional, and environmental assessment must be created and shared with the patient with monitoring and updating as needed.

• Services are reported once per calendar month.

Table 1. Chronic Care Management Codes and Examples

Codes Examples

99487 Complex CCM services, with the following required elements:• multiple (two or more) chronic conditions expected to last at least

12 months, or until the death of the patient,• chronic conditions place the patient at significant risk of death,

acute exacerbation/decompensation, or functional decline,• establishment or substantial revision of a comprehensive care plan,• moderate or high complexity MDM;• 60 minutes of clinical staff time directed by a physician or other

qualified health care professional, per calendar month.+99489 each additional 30 minutes of clinical staff time directed by a

physician or other qualified health care professional, per calendar month (List separately in addition to 99487)

A 3-year-old patient has Down syndrome (trisomy 21) and history of atrioventricular septal defect, mitral valve regurgitation, hypothyroid-ism, recurrent pulmonary infections, and chronic bilateral otitis media. The primary care pediatrician coordinates with cardiologist, pulmonol-ogist, otolaryngologist, physical therapist, occupational therapist, and speech-language therapist. A care plan is developed and/or revised for management/treatment for each condition. Clinical staff time spent in CCM activities is at least 60 minutes in a calendar month. Moderate- or high-complexity MDM is documented.

#99490 CCM services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:• multiple (two or more) chronic conditions expected to last at least

12 months, or until the death of the patient;• chronic conditions place the patient at significant risk of death,

acute exacerbation/decompensation, or functional decline;• comprehensive care plan established, implemented, revised, or

monitored.

An adolescent patient with type 1 diabetes, hypothyroidism, and celiac disease requires care planning and frequent contact to prevent hypoglycemic episodes and weight loss. The patient’s pediatrician supervises clinical staff, who spend 25 minutes in care coordination and communication with the patient and family during a calendar month.

#99491 CCM services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month, with the following required elements:• multiple (two or more) chronic conditions expected to last at

least 12 months, or until the death of the patient;• chronic conditions place the patient at significant risk of death,

acute exacerbation/decompensation, or functional decline;• comprehensive care plan established, implemented, revised,

or monitored.

A 3-year-old patient has Down syndrome (trisomy 21) and history of atrioventricular septal defect, mitral valve regurgitation, hypothyroid-ism, recurrent pulmonary infections, and chronic bilateral otitis media. A primary care pediatrician coordinates care with a cardiologist, pulmonologist, otolaryngologist, physical therapist, occupational therapist, and speech-language therapist. A care plan is developed, monitored, or revised for each condition. The pediatrician personally spends a total of 35 minutes in CCM activities during the calendar month and reports code 99491 in addition to codes for face-to-face E/M services provided.

Abbreviations: CCM, chronic care management; E/M, evaluation and management; MDM, medical decision-making.



Chronic Care Management: Current Coding Options...continued from page 3

• Time and the name of the individual (including credentials) performing each CCM activity during the month must be documented to support the total time of CCM services.

See the prefatory text of your Current Procedural Terminology ® reference for specific requirements of practices providing CCM services and activities that are included in CCM service time.

DifferencesDifferences in CCM services are shown in Table 2. Note that only code 99491 requires that the reporting physician or QHP personally spend the required time providing CCM services. Codes 99487 and 99489 require moderate- to high-complexity medical decision-making and more than monitoring or minimal change to the care plan.

The current Medicare Physician Fee Schedule (MPFS) conversion factor is $36.0391 per relative value unit. Using the national average MPFS values (actual payment varies by geographic location), payment for CCM services ranges from $42.17 for code 99490 to $92.98 for code 99487. This illus-trates the potential return on investment of providing and reporting CCM services.

If just 10 patients require 20 minutes of clinical staff time per calendar month spent in CCM activities (eg, patient education, coordination of care with other health care professionals), a practice should expect approximately $420 for these services. Additionally, the attention to the care plan and patient engage-ment that are components of CCM services may also support payment from certain medical home or value-based payment programs (eg, a share in savings seen from reduced cost of care).

More Information on Chronic Care Management ServicesSee Chapter 12 of Coding for Pediatrics 2020 for more informa-tion and examples of CCM services.

Previous AAP Pediatric Coding Newsletter™ articles addressing CCM services include

• “New Chronic Care Management Code,” October 2018 (https://coding.solutions.aap.org/article.aspx?articleid=2705069)

• “Sorting Out Care Management in 2018,” November 2017 (https://coding.solutions.aap.org/article.aspx?articleid= 2660026)

• “You Code It! Chronic Care Management Services (Online Exclusive),” April 2017 (https://coding.solutions.aap.org/article.aspx?articleid=2613607)

Some health plans still consider these services bundled (ie, not separately paid for) or require members to receive care management through the health plan’s care management nurses. However, not identifying your patients with chronic health condi-tions whose health benefits include payment for CCM services might equate to missed revenue and opportunities to provide these valuable services.

Table 2. Chronic Care Management Code Differences in 2019–2020

Code Service RequirementPhysician or QHP Time Clinical Staff Timea

Work/Non-facility Total RVUs (Unadjusted)

Total Non-facility RVUs × $36.0391

99487 • Requires moderate- or high-complexity MDM.• Care plan must be established or substantially

revised.• Typical pediatric patients receive ≥3 therapeu-

tic interventions.

None 60 min per calendar month

1.0/2.58 $92.98

99489 Each additional 30 min in a calendar month

0.50/1.29 $46.49

#99490 Requires establishing, implementing, revising, or monitoring a care plan.

None 20 min per calendar month

0.61/1.17 $42.17

#99491 Requires establishing, implementing, revising, or monitoring a care plan.

30 min per calendar month

Noneb 1.45/2.33 $83.97

Abbreviations: CCM, chronic care management; MDM, medical decision-making; QHP, qualified health care professional; RVU, relative value unit.a Physician or QHP time may be combined with clinical staff time to support codes 99487, 99489, and 99490. Time counted toward CCM service is not counted to support reporting of other services.

b Clinical staff time is not included in the time supporting code 99491.

TIPWhen a patient is identified as having 2 or more chronic health conditions that support the need for CCM services, practice support staff should identify the patient’s health plan benefits (payment policy). Where physician practice-based CCM services are not separately paid, the health plan may offer alternative covered services or programs to support a pediatri-cian’s care plan.



Subspecialty Coding: CPT ® 2020—Long-term Electroencephalogram CodesCodes 95700–95726 have been added, effective for dates of service on and after January 1, 2020, for long-term continuous- recording electroencephalograms (EEGs), along with new defini-tions and reporting instructions. Unlike routine EEGs (95812, 95813, 95816, 95819, 95822) that capture brain wave activity for fewer than 2 hours, long-term continuous-recording EEGs capture brain wave activity for 2 hours or longer to monitor treatment of seizures and status epilepticus. The length of recording is based on multiple factors, including the clinical indication for the test and frequency of seizures.

Deleted CodesCodes 95950–95953 and 95956 (monitoring for identification, lateralization, or localization) and 95827 (EEG with all-night recording) are deleted in 2020, as these services will be reported with the new long-term EEG codes.

New CodesCodes 95700–95726

• Must include at least 2 hours of recording. Recording time of 1 to 119 minutes is reported with routine EEG codes.

• May be reported for any site of service.

• May span multiple recording dates.

• Are not reported in conjunction with routine and extended EEG codes 95812, 95813, 95816, 95819, 95822, and 95824.

• Are divided for technical and professional components.

− The technical component (eg, technician time, equipment) is reported with codes 95700–95716

− The professional component (interpretation and report only) is reported with codes 95717–95726.

• Are selected based on the EEG/video EEG (VEEG) recording time.

− Recording time is when the recording is underway and diagnostic EEG data are being collected.

− Recording time excludes setup and takedown time.

− If diagnostic EEG recording is disrupted, recording time stops until diagnostic EEG recording is resumed.

TIP All-night EEG

Code 95827 (EEG with all-night recording) is deleted in 2020. Report all-night recording with long-term EEG codes 95717 and 95718 (professional component) or 95705–95707 or 95711–95713 (technical component).

• May be reported in conjunction with codes 95961 and 95962 when functional cortical or subcortical mapping is performed with long-term EEG recording.

• Include all-night recording (see codes 95705–95707, 95711–95713, or 95717 and 95718).

• Include use of automated spike and seizure detection and trending software use, when performed. Do not separately report code 95957 (digital analysis of EEG) for use of auto-mated software.

This article focuses on reporting the professional component (interpretation and report) of long-term EEG services. Please see Current Procedural Terminology (CPT ®) 2020 (manual or software) for detailed information on codes for reporting the technical component of long-term EEG services.

Reporting InstructionsLong-term EEG codes 95717–95726 do not include any evalua-tion and management (E/M) services; any E/M service provided by the same individual is separately reportable.

Code selection for professional interpretation of long-term EEG is based on

• Length of the recording being interpreted

• Recording with or without video

Additionally, code selection for EEG recording of longer than 36 hours is based on whether the diagnostic interpretations and reports of the physician or other qualified health care profes-sional (QHP) are generated in either of the following ways:

• Daily with a summary report at the end of the study.

• The entire professional interpretation is performed after the entire study is completed (including when separate reports are documented for each day after the entire study is complete).

Timing of Physician Interpretation and Report

Codes 95717–95720 are reported when physician interpre-tation and report take place after each 24 hours of recording.

In contrast, codes 95721–95726 are reported for long-term EEG when the interpretation and report take place only at the end of the study (summary and reports for each 24 hours, when performed).


Subspecialty Coding: CPT ® 2020—Long-term Electroencephalogram Codes...continued from page 5

Reporting Electroencephalogram Recording of 2 to 36 HoursEEG recording of 2 to 36 hours is reported with codes 95717–95720.

#•95717 Electroencephalogram, continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and report, 2–12 hours of EEG recording; without video

#•95718 with video (VEEG)

#•95719 Electroencephalogram, continuous recording, physician or other qualified health care professional review of recorded events, analysis of spike and seizure detection, each increment of greater than 12 hours, up to 26 hours of EEG recording, inter-pretation and report after each 24-hour period; without video

#•95720 with video (VEEG)

Codes 95717–95720 include all of the following:

• Review of the recorded data

• Daily interpretation and report (each 24 hours) by the physi-cian or QHP, when applicable

• Summary report for the entire study

Table 1 illustrates the decision points for code selection when EEG recording with or without video lasts at least 2 hours and up to 36 hours.

Table 1. Long-term Electroencephalogram Code Selection for 2 to 36 Hours of Recording

EEG Recording Time (h) With Video Without Video

<2 Report routine EEG (95812, 95813, 95816, 95819, 95822).

2–12 95717 95718

>12–26 95719 95720

>26–36 95719 and 95717 95720 and 95718

>36 See tables 2 and 3.

Abbreviation: EEG, electroencephalogram.

Codes 95717–95720 are also reported for long-term EEG service of longer than 36 hours with daily interpretation and report (each 24 hours). Multiple codes are reported for long-term EEG services of longer than 36 hours. Table 2 shows the decisions for selecting codes and units of service reported for these services.

Table 2. Decision Table: Reporting Electroencephalogram Recording of Longer Than 36 Hours With Report Each 24 Hours

Select With or Without Video With Video Without Video

Select time of service with code(s) and units of service.

36 h 1 min–50 h95720 × 2

36 h 1 min–50 h95719 × 2

50 h 1 min–60 h95720 × 2 and 95718 × 1

50 h 1 min–60 h95719 × 2 and 95717 × 1

60 h 1 min–74 h95720 × 3

60 h 1 min–74 h95719 × 3

74 h 1 min–84 h95720 × 3 and 95718 × 1

74 h 1 min–84 h95719 × 3 and 95717 × 1

84 h 1 min–98 h95720 × 4

84 h 1 min–98 h95719 × 4

Codes/TimesWith video: 95718/2–12 h; 95720/12 h 1 min–26 hWithout video: 95717/2–12 h; 95719/12 h 1 min–26 h

When the entire interpretation and report (including retrospective daily reports and summary report) is made after completion of the entire study, report codes 95721–95726.

#•95721 Electroencephalogram, continuous recording, physi-cian or other qualified health care professional review of recorded events, analysis of spike and seizure detection, interpretation, and summary report, complete study; greater than 36 hours, up to 60 hours of EEG recording, without video

#•95722 greater than 36 hours, up to 60 hours of EEG recording, with video (VEEG)

#•95723 greater than 60 hours, up to 84 hours of EEG recording, without video

#•95724 greater than 60 hours, up to 84 hours of EEG recording, with video (VEEG)

#•95725 greater than 84 hours of EEG recording, without video

#•95726 greater than 84 hours of EEG recording, with video (VEEG)

Table 3 provides a decision table for determining code selection for EEG service of longer than 36 hours with or without video.

Table 3. Decision Table: Reporting Electroencephalogram Record-ing of Longer Than 36 Hours With Report at Conclusion of Entire Recording Period

Select With or Without Video With Video Without Video

Select time of service with code(s) and units of service.

36 h 1 min–60 h95722 × 1

36 h 1 min–60 h95721 × 1

60 h 1 min–84 h95724 × 1

60 h 1 min–84 h95723 × 1

84 h 1 min–98 h95726 × 1

84 h 1 min–98 h95725 × 1

Additional information and charts can be found in CPT ® 2020.


You Code It!

Neonatal Critical Care

Can you assign the appropriate procedure and diagnosis codes for the following scenario? Answers can be found later in this newsletter.

A neonatologist is providing critical care services to a 700-g, 26-weeks’ postmenstrual-age neonate who was born at another facility and transferred on the same date to a tertiary care facility. The neonate remains critical and on mechanical

ventilation for respiratory distress syndrome at 7 days following birth. The neonate receives no feedings by mouth and is receiving total parenteral nutrition. The neonatologist removes an existing umbilical venous catheter due to increasing risk of central catheter-associated blood stream infection and places a peripherally inserted central catheter.

Chronic Care Management: Current Coding Options...continued from page 4

Adding Chronic Care Management Services in Your PracticePractices preparing to provide CCM services must consider many factors, including

• Identification of eligible patients and insurance benefits

• Developing staffing and workflows

• Electronic health record (EHR) functionality and vendor support

− Comprehensive care plan documentation

− Task assignment

− Documentation of activities between encounters

− Time tracking

− Registry functions

This may entail up-front investments to provide CCM services. Because of this, it is important to first identify patients in your practice who have qualifying health conditions and commonly require assistance between visits. By identifying the number of qualifying patients who may require 20 or

more minutes of clinical staff time per calendar month, a practice can develop its CCM program with staffing and resources appropriate to the patient panel and expected long-term return on investment.

CCM requires use of an EHR so that clinicians have timely access to the patient’s health information. Many EHRs will require revisions to include features to support documentation of CCM services. EHR vendors may offer assistance with this. Also, EHR user groups may include members who have developed EHR templates to support provision of CCM services. If it is cost prohibitive to alter an EHR, other software might be used for some functions (eg, activity logs, time-tracking software) with documentation imported into the EHR.

Once initiated, practices may wish to explore opportunities for leveraging the value of CCM services beyond the monthly fee-for-service payment. With accumulated evidence of quality improvement and/or cost savings, a practice may find additional revenue in the form of quality improvement incentives and/or shared-savings opportunities.

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· · · Coding Hotline · · ·ICD-10-CM: In utero Cerebrovascular Accident

I have assumed primary care management of a child with spastic hemiplegic cerebral palsy caused by an in utero cerebrovascular accident (CVA). I feel the in utero CVA has continued to affect the child’s health care needs. Should I assign a code for this? Would I report a code from category I69 for sequelae of cerebrovascular disease?

Yes and no. Because you indicate a link between the cerebral palsy and the in utero CVA, it is appropriate to code both conditions. However, the correct codes would be as follows:

G80.2 Spastic hemiplegic cerebral palsy

P91.0 Neonatal cerebral ischemia

International Classification of Diseases, 10th Revision, Clinical

Modification (ICD-10-CM) instructs that codes in category I69 are used to indicate conditions in categories I60–I67 as the cause of sequelae. This is not the case for the child who had an in utero CVA. The child’s CVA occurred during the peri-natal period and continues to have an effect on the child’s health care; therefore, the perinatal code should continue to be used regardless of the patient’s age.

CPT®: Screening Eye Examinations

Is it appropriate to report code 99173 when a screening eye examination is performed in addition to the code for a well-child visit?

Yes. Although a health plan may have a policy that bundles the screening eye examination to the preventive medicine evaluation and management (E/M) service, code 99173 (screening test of visual acuity, quantitative, bilateral) is appro-priately reported in addition to the preventive medicine E/M code per Current Procedural Terminology (CPT ). CPT instructs, “Vaccine/toxoid products, immunization administra-tions, ancillary studies involving laboratory, radiology, other procedures, or screening tests (eg, vision, hearing, develop-mental) identified with a specific CPT code are reported separately” (emphasis added). Screening service codes are reported only in the absence of signs or symptoms. Diag-nostic eye examinations are not reported with code 99173. See codes for E/M or general ophthalmological services.

A letter to health plans about separate payment for screening eye examinations is available at https://coding.solutions.aap.org/ss/resources.aspx (see “Vision Screen” under the Payer Appeal Letters for Claims Denial section).

When using an instrument-based screening tool, see codes 99174 and 99177.

99174 Instrument-based ocular screening (eg, photo-screening, automated-refraction), bilateral; with remote analysis and report

#99177 with on-site analysis

ICD-10-CM: Suspected Measles

We have seen several patients whose parents were concerned they may have measles due to outbreaks in the area. What diagnosis code should we report if the patient does not have measles or another rea-son for the visit (eg, rash, roseola)?

This will depend on the specific circumstances of each encounter. The Table on page 12 offers a quick reference to coding encounters for suspected conditions that are ruled out.

In the absence of signs or symptoms or other diagnoses, if the parents report a known exposure to measles, or if a local epidemic of measles has occurred, ICD-10-CM code Z20.828 (contact with and [suspected] exposure to other viral communicable diseases) should be reported. Codes in category Z20 are for patients who do not show any sign or symptom of a disease but have been exposed to it by close personal contact with an infected individual or are in an area where a disease is epidemic.

If the patient has not been directly exposed and no local outbreak of disease has occurred, a code for contact or exposure cannot be reported. In the absence of another reason for the encounter, physicians must turn to the reporting of signs and symptoms or a suspected condition that is ruled out.

When a patient presents for a suspected condition that is ruled out during the encounter with no findings of symptoms or other diagnosis to report, it would be appropriate to report code Z03.89 (encounter for observation for other suspected diseases and conditions ruled out) as the first-listed or sole diagnosis. However, if symptoms are evaluated and managed or a diagnosis of another condition results, the code for the symptom or condition should be listed first. Exception: When the patient is a neonate presenting with no signs or symp-toms, report code Z05.1 (observation and evaluation of newborn for suspected infectious condition ruled out).


You Code It! Answers

Neonatal Critical CareThe “You Code It!” scenario earlier in this newsletter focused on neonatal critical care with insertion of a peripherally inserted central catheter (PICC) in a 7-day-old. The correct codes for this encounter are shown in the Table.

Diagnosis and Procedure Codes

Diagnosis Codes Procedure Codes

P22.0 Respiratory distress syndrome of newborn

P92.8 Other feeding problems of newborn

P07.02 Extremely low birth weight newborn, 500-749 grams

P07.25 Extreme immaturity of newborn, gestational age 26 completed weeks

99469 25 Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger

P92.8P22.0

36568 Insertion of peripherally inserted central venous catheter (PICC), without subcutaneous port or pump, without imaging guidance; younger than 5 years of age

All the conditions that contribute to the need for critical care services and that influence the neonatologist’s medical decision-making should be included on the claim and linked to the code for subsequent daily neonatal critical care. (Note that only the physician directing the daily management of the critically ill or critically injured neonate’s overall care will report daily neonatal critical care. Other physicians who see the patient intermittently to manage one or more conditions should report the appropriate subsequent hospital care or hourly critical care codes, as applicable.)

The appropriate codes for the respiratory distress and feeding issues that support the need for total parenteral nutrition should be linked to the code for placement of the PICC.

TIPFor PICC placement, without subcutaneous port or pump, with imaging guidance (eg, ultrasound), in a patient younger than 5 years, use code 36572 in lieu of code 36568.

Note that no code from the Z38 series (live-born infants according to place of birth and type of delivery) is reported because this is not the birth admission. The neonate was born at another hospital and transferred to the facility where the neonatol-ogist is providing care.

Is the Peripherally Inserted Central Catheter Bundled?When you determined your answers to the scenario, did you leave off code 36568, considering it bundled with (ie, included in) the daily neonatal critical care? In this coding scenario, the neonatologist performs both services. However, the following should be considered when coding these services:

• Current Procedural Terminology (CPT ®) does not bundle these 2 services. Code 36568 is not included in the list of codes bundled with neonatal critical care services.

• National Correct Coding Initiative (NCCI) edits pair code 99469 with code 36568 but allow for payment of both services when a modifier is appropriately appended to override the edit.

• Both CPT and NCCI allow reporting of a significant and separately identifiable evaluation and management (E/M) service (eg, neonatal critical care) at the same encounter as a minor procedure.

The Medicare NCCI manual (used by many private health plans) advises that if a provider submits the 2 codes of an edit pair for payment for the same beneficiary on the same date of service, the Column 1 code is eligible for payment and the Column 2 code is denied. However, if both codes are clinically appropriate and an appropriate NCCI-associated modifier is used, the codes in both columns are eligible for payment.

Because the neonatal critical care service entails work significantly beyond the pre- and post-service work of PICC placement, modifier 25 is appropriately appended to code 99469 in this scenario. Note that modifier 59 is not appended to 36568 because this modifier is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

If an advanced practice professional had placed the PICC, he or she would bill the PICC under his or her own National Provider Identifier, with the neonatologist billing only for services personally performed (in this scenario, neonatal critical care).


Many pediatricians select codes for services within an electronic health record (EHR), but the code selection tools in many EHRs provide little beyond an abbreviated code descriptor. To confi-dently assign codes and answer pediatric coding questions, pedi-atricians can turn to the American Academy of Pediatrics (AAP).

In addition to the web-based resources listed in this article, the AAP also offers a full award-winning suite of annually updated coding products, including Coding for Pediatrics 2020, Pediatric

ICD-10-CM 2020, coding quick reference cards, and webinars. Learn more at https://shop.aap.org/coding.

Coding at the AAPStay up-to-date and find useful coding resources from AAP coding experts by visiting the AAP dedicated coding website, Coding at the AAP (https://aap.org/coding). On the site, you will find documents and guidance designed to help make it easier to get paid. Clicking “Coding Resources” will guide you to the resources listed in the Table.

AAP Coding HotlineHave a coding question? Enter it online at https://coding.solutions. aap.org/coding-hotline.aspx and our team will reach out with assistance.

Do You Have the Coding Resources You Need for 2020?

Table 1. Current Online Coding Resources

Website Section Contentsa

CMS Coding and Payment Policies

• AAP Position on Medicare Consultation• Guide to RAC Programs• Primary Care Exception Rule

Code Valuation and Payment RBRVS

• 2019 Final Rule Summary for Pediatricians• 2019 RBRVS: What Is It And How Does It Affect

Pediatrics? − 2019 RBRVS Conversion Spread Sheet

• AAP Comments on 2020 RBRVS Proposed Rule • Application of the Resource-Based Relative Value

Scale System to Pediatrics Policy Statement• Medicare Conversion Factor History • The Bottom Line: Getting Paid for What You Do• Physician Fee Schedule Increase Under ACA—

Updated for 2014• RUC Survey Training

National Correct Coding Initiative (NCCI) Edits

• Current Procedure-to-Procedure (PTP) and Medically Unlikely Edit (MUE) Coding Edits Files

• FAQ NCCI Medicaid Edits• National Correct C oding Initiative Medicare Edits• Modifier 59 and its Use in Overriding NCCI Edits

Vaccine Coding • Template Comment Letter for Members on Immunization Administration

• Vaccine Counseling and Preventive Care Visits• Influenza Vaccines: Coding for the Current Season• Vaccine Coding Table • When Is It Appropriate to Report an E/M Service

During Immunization Administration?• FAQ—Pediatric Immunization Administration Codes• CDC Vaccine Price List• New Versus Established Patient Status After

Vaccine Only Encounter

Website Section Contentsa

Evaluation and Management

• 1995 CMS Documentation Guidelines• 1997 CMS Documentation Guidelines• E/M Documentation and Audit Guidelines• Coding Calculator • Coding Tips for Pediatricians: Evaluation and

Management Coding Strategies• New Vs Established Patient• Prolonged Services (Direct) Reporting• Time Based E/M Services and Coding When

Patient is not Present• What is Included in Preventive Medicine

Encounters: Template Letter

CPT and Modifiers

• E/M Documentation and Audit Guidelines• Coding Calculator• Coding Development and CPT Change Request• Top Ten Current Procedural Terminology

Questions (Including Modifiers)• Modifier 25 Primer: Use It—Don’t Abuse It!• Category II CPT Codes

Coding Fact Sheets

• Adolescent Health • After Hours and Special Services • Asthma• Breastfeeding and Lactation• Bright Futures and Preventive Medicine • Developmental Screening/Testing and Emotional

Behavioral Assessment • Fetal Alcohol Syndrome• Hearing Screening• Inattention, Impulsivity, Disruptive Behavior,

and Aggression• Medical Home • Mental Health

− ADHD − Anxiety − Bereavement − Depression − PTSD

• Oral Health• Osteopathic Manipulation Therapy Coding

Fact Sheet • Substance Use• Telehealth/Telemedicine Service s • Tobacco• Transition Care for Adolescents Tip Sheet• Trauma • Billing Position Papers

− Understanding Adolescent Confidentiality As It Relates To Billing

Abbreviations: AAP, American Academy of Pediatrics; ACA, Patient Protection and Affordable Care Act; ADHD, attention-deficit/ hyperactivity disorder; CDC, Centers for Disease Control and Prevention; CMS, Centers for Medicare & Medicaid Services; CPT, Current Procedural Terminology; E/M, evaluation and management; FAQ, frequently asked questions; PTSD, posttraumatic stress disorder; RAC, Recovery Audit Contractor; RBRVS, Resource-Based Relative Value Scale; RUC, American Medical Association/Specialty Society Relative Value Scale Update Committee. a Contents current as of October 1, 2019.


ONLINE EXCLUSIVE

Test your knowledge with a crossword puzzle related to this month's newsletter contents at https://coding.solutions.aap.org.

AAP Pediatric Coding WebinarsPRESENTED BY THE

For more information and to register, visit www.aap.org/webinars/coding.

AAP coding products—WINNER OF THE

2019 AMA Excellencein Coding Education

AWARD!

Pediatric Coding Updates: Stay Current for 2020! Don’t Continue Leaving Money on the Table NOVEMBER 11, 2019 NOON CST DECEMBER 11, 2019 NOON CST

David M. Kanter, MD, MBA, CPC, FAAP Linda D. Parsi, MD, MBA, CPEDC, FAAP This 60-minute webinar will discuss

• New updates to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM ) and Current Procedural Technology (CPT ®) code sets

• Relevant pediatric ICD-10-CM codes, such as travel counseling, more specific codes for adenosine deaminase deficiency and Ehlers-Danlos syndrome, and more

• Proposed relative value units for new CPT services • Specific examples on the use of the most common CPT codes

This 60-minute webinar will discuss

• Commonly overlooked services and supplies • Use of ICD-10-CM codes to support services, with a special focus on coding for

social determinants of health• Importance of proper modifier use • Additional coding opportunities to help your bottom line

These coding webinars have the prior approval of the American Academy of Professional Coders (AAPC) for 1.0 continuing education hours (CEUs). Granting of prior approval in no way constitutes endorsement by AAPC of the program content or the program sponsor.

The American Academy of Pediatrics Committee on Coding and Nomenclature and Private Payer Advocacy Advisory Committee have updated the 2014 policy statement, “Application of the Resource-Based Relative Value Scale System to Pediatrics.” The revised policy statement, along with an accompanying technical report, is titled, “Pediatric Application of Coding and Valuation Systems.”

The policy statement addresses health care changes that affect procedural and visit coding and valuation as well as the incor-poration of coding principles into innovative, newer payment models. It also emphasizes the importance of understanding the basic concepts underlying Current Procedural Terminology

(CPT ®); International Classification of Diseases, 10th Revision,

Clinical Modification (ICD-10-CM); and other code sets to support effective payment and payer communication.

While the policy statement itself focuses solely on recommen-dations, the accompanying technical report provides supple-mental coding and valuation background. The policy statement is separated into 2 sections, Coding and/or Valuation System Recommendations and CMS- and/or Payer-Focused Recommendations. The recommendations in each section are as follows:

Coding and/or Valuation System Recommendations1. Confirm the importance of the Resource-Based Relative

Value Scale.2. Engage in the American Medical Association-Specialty Society

Relative Value Scale Update Committee (RUC) survey process.

AAP Updates Policy on Pediatric Application of Coding, Valuation Systems

3. Support Centers for Medicare & Medicaid Services (CMS) relative value unit publication of RUC-valued services.

4. Encourage full-spectrum acknowledgment of CPT codes and guidance.

5. Develop relevant quality measures.6. Optimize ICD-10-CM impact on payroll.7. Recognize pediatric-specific services.

CMS- and/or Payer-Focused Recommendations1. Improve comparative Medicaid payment.2. Develop a national Medicaid database.3. Expedite G-code transition to CPT.

4. Align regulatory correlation with CPT codes.

For additional information, visit https://www.aappublications. org/news/2019/09/30/coding093019, https://pediatrics. aappublications.org/content/144/4/e20192496, and https:// pediatrics.aappublications.org/content/144/4/e20192498.

https://www.aappublications.org/news/2019/09/30/coding093019

https://www.aappublications.org/news/2019/09/30/coding093019

https://pediatrics.aappublications.org/content/144/4/e20192496




https://coding.solutions.aap.org/article.aspx?articleid=2753643

MIXED SOURCES12 | AAP Pediatric Coding Newsletter™ | http://coding.aap.org | November 2019

AAP Pediatric Coding Newsletter™ November 2019 | Vol 15, No. 2

1. Which of the following chronic care management

services requires medical decision-making of at least

moderate complexity?

a. 99490

b. 99491

c. 99495

d. 99487

2. What is the least amount of time a long-term electro-

encephalogram (EEG) recording reported with codes

95700–95726 can be?

a. 24 hours

b. 26 hours

c. 2 hours

d. 2 days

3. Code selection for the professional component of

long-term EEG recording is affected by which of the

following?

a. EEG recording includes video.

b. The length of the recording

c. Interpretation and report take place after each 24 hours.

d. All of the above

Find your quiz answers at http://coding.aap.org.

4. Which of the following is true?

a. Current Procedural Terminology (CPT ®) prohibits report-

ing placement of a peripherally inserted central catheter

in addition to codes for neonatal or pediatric critical care.

b. The National Correct Coding Initiative (NCCI) edits never

allow reporting of code 36568 with code 99469.

c. Both CPT and NCCI allow reporting of a significant and

separately identifiable evaluation and management (E/M)

service at the same encounter as a minor procedure.

d. Modifier 59 is used to identify procedures or services

reported on the same date as a significant, separately

identifiable E/M service.

5. Codes in International Classification of Diseases, 10th

Revision, Clinical Modification category Z20 are

reported for which of the following?

a. Observation and evaluation of newborn for suspected

diseases and conditions ruled out

b. Encounter for observation for other suspected diseases

and conditions ruled out

c. Contact with and (suspected) exposure to other viral

communicable diseases

d. Signs and symptoms of an infectious condition

0.5 Continuing Education Units

NEW FOR 2020!Award-winning pediatric coding resources FROM THE AAP

To order visitshop.aap.org/books

Do not use a code from category Z05 when a neonate has iden-tified signs or symptoms of a suspected problem; in such cases, code the sign or symptom.

Diagnosis Coding Options for Suspected Conditions, Ruled Out

Context of Visit Diagnosis Code

Signs/symptoms reported

Assign codes for signs/symptoms and Z03.89 (encounter for observation for other suspected diseases and conditions ruled out) or Z05.-a (observation and evaluation of newborn for suspected diseases and conditions ruled out).

Contact with and (suspected) exposure without sign and symptoms

Z20.828 Contact with and (suspected) exposure to other viral communi-cable diseases

No signs or symptoms and no suspected exposure

Child other than neonate: Z03.89Neonate: Z05.-a

a Dash (-) indicates additional characters are required.

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