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aappediatric
codingnewsletter
Volume 9, Number 10
July 2014
™
The American Academy of Pediatrics peer-reviewed coding and nomenclature newsletter
IN THIS ISSUE
4
5
6
7
-
Professional Component Services: More Than Codes
Documenting Abdominal
Pain or Tenderness
Adaptive Behavior
Assessments and
Treatment
Q&A
-
Oral Health Services
Update
You Code It!
AAP Pediatric Coding Newsletter™ Quiz
When physicians provide diagnostic services, payer policy may dictate not only
codes and modifiers to be reported but other important information deemed
necessary for proper claim payment.
Codes and Modifiers
Many diagnostic services may be performed and billed by a single practitioner
performing the complete service or split between 2 practitioners, with one billing
for the technical component of the service and the other the professional component. Medicare and most payers use modifiers 26 (professional component) and
TC (technical component) to describe the professional and technical components of
service when the components are separately performed and reported. No modifier
is necessary when one entity performs both components.
Example
A patient has a 2-view chest radiograph taken at an outpatient radiology practice and
transports the films to the physician’s office for interpretation. The physician performs
the interpretation and report. This service is reported as follows:
71020 26 Radiological examination, chest, two views, frontal and lateral
The outpatient radiology practice would report 71020 TC for the technical
component of the service.
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CODING TIP
It is not appropriate to report the number of views as the number of units of service when
the code reported includes the number of views (eg, a 2-view chest radiograph is reported
with code 71020 and one unit of service).
Certain services are reported with codes that identify the service as complete,
professional only, or technical only. The most common of these may be the
electrocardiogram (ECG). For these services, no modifier is necessary.
Example
93000
93005
93010
Electrocardiogram, routine ECG with at least 12 leads; with
interpretation and report
tracing only, without interpretation and report
interpretation and report only
A physician interpreting an ECG tracing produced by another practitioner (ie, not by
the physician’s staff and equipment) would only report code 93010 for the interpretation
and report. However, if the tracing is generated with physician’s equipment in the practice and the physician provides the interpretation and report, code 93000 is reported.
(continued on page 2)
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Professional Component Services: More Than Codes (continued from page 1)
CODING TIP
Payers typically pay only one physician or practitioner for the
professional component of a diagnostic service (ie, interpretation
and report). When diagnostic results (eg, image, tracing) are
reviewed as part of an evaluation and management (E/M) service
but another physician (eg, radiologist) will provide the formal
interpretation and report, the physician reviewing the result should
consider the independent review as a factor in the level of medical
decision-making performed. However, a physician who provided
the formal interpretation and report in conjunction with an E/M
service may report both services with modifier 25 appended to
the E/M service.
Date and Place of Service
Reporting codes and modifiers for the technical and professional components is fairly straightforward. But a claim also
must include the date and place of service (POS). Payment for
many services is based on whether the service is provided in
a facility (eg, inpatient or outpatient hospital) or non-facility
setting (eg, physician office), recognizing differences in
practice expense.
Although Medicare policy specifically defines the date of service for laboratory tests (ie, date the specimen was obtained),
no specific guidance is provided for the professional component of other diagnostic services. Several billing management
and specialty organizations have requested that the Centers
for Medicare & Medicaid Services (CMS) adopt a national
standard that the date of service for the professional component of a diagnostic test is reported as the date on which
the technical component was performed. However, some
Medicare contractors require the actual date of the inter-
pretation and report, and private payers may also adopt
this policy. As with many questions in medical billing, it
is important to verify the individual payer’s policy.
CODING TIP
Although payer policy may determine the date of service to be
reported, it is good practice to include in the professional report
the date, site, and time (if noted) of the technical component and
the date of interpretation. This creates an important link between
the test results or images and the interpretation and report for
future reference. This is particularly helpful when the same test
is performed more than once.
A POS is typically reported as the place where the technical
or face-to-face component of the service was provided. This
is based on Medicare policy (Medicare Claims Processing
Manual, Chapter 13, Section 150). Although pediatricians
may see few Medicare patients, the policies established by
Medicare are often adopted by private payers and Medicaid
plans, making this information notable to all physicians.
However, this may not be true for all payers, making it necessary to verify individual payer policies.
The following examples may be helpful in determining the correct POS for professional component services:
Examples
A physician orders anteroposterior and frog-leg radiographs of the left hip of a child. The radiographs are produced in the
physician’s office and the physician performs the interpretation and report. The service is reported with code 73510,
radiologic examination of the hip, unilateral; complete, minimum of 2 views. Place of service 11 (office) is appropriate and
no modifier is required because the technical and professional
components were provided in the practice’s office.
CODING TIP
A payer may also require that modifier LT be appended to identify
the hip that was studied.
A patient undergoes an ECG as an outpatient at the hospital.
The tracing is generated and transmitted electronically to the
patient’s physician, who interprets it and creates a report in
her office the next day. Because the physician is providing
only the interpretation and report, code 93010 is reported.
The physician performs the service in the office but the POS
is generally reported based on the site where the patient
received the technical component of the service—in this case,
outpatient hospital reported with POS code 22. Although the
POS code identifies an outpatient facility, the practice location (ie, physician’s office address) is identified in field 32 of
the CMS-1500 claim form or its electronic equivalent.
A hospital inpatient undergoes an electromyogram and nerve
conduction studies in the hospital’s neurology department.
Test results are accessed electronically by a physician working
in her office. She reports the appropriate procedure codes for
each test with modifier 26 appended and POS 21 for inpatient hospital (unless payer guidance directs otherwise).
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CODING TIP
When a patient who is a registered inpatient of a facility undergoes
services in an outpatient clinic or office during his or her admission,
a payer may require reporting of the service with the inpatient
place of service (eg, inpatient hospital 21, inpatient rehabilitation
facility 61) due to contractual obligations of the facility to provide
the technical and practice expense components of services during
the stay.
technical and professional components because its lease includes
use of the equipment and a radiology technician’s services. Most
payers will require that the services be reported with POS office
(11) because the mobile unit is serving as an extension of the
practice. However, it is necessary to confirm individual payer
policy, as POS 15 (mobile unit) may be required by some payers.
Finding the Place of Service Code
A physician is attending an educational seminar at a hotel; that Many billing systems incorporate POS codes in the charge
entry function. However, a list of all POS codes is included in
evening, he or she accesses a diagnostic image or tracing via
the front of the Current Procedural Terminology® manual pubsecure electronic health interchange and provides an interpretation and report from the hotel room. Although the physician lished by the American Medical Association and online in
was not in his or her office, Medicare policy is that the service Chapter 26, Completing and Processing Form CMS-1500
would be reported using the POS code for the location where Data Set, of the Medicare Claims Processing Manual (please
the technical component was performed and the practice loca- see the “Internet-Only Manuals [IOMs]” link on the left side
tion (field 32) where the physician typically provides this type of the page at www.cms.gov/manuals for the current version).
Chapter 26 of the Medicare Claims Processing Manual also
of service (eg, office practice, outpatient facility).
provides instructions for selecting the appropriate POS code.
A physician practice has a contract with a mobile radiology ser- The following Table includes select POS codes for locations
vice to provide the technical component of radiology services commonly reported for physician services:
outside its rural office twice per month. The practice bills for the
Commonly Reported Place of Service Codesaace of Servicea
Office: Location, other than a hospital, skilled nursing facility, military treatment facility, community health center, state or local public
health clinic, or intermediate care facility, where the health professional routinely provides health examinations, diagnosis, and
treatment of illness or injury on an ambulatory basis.
11
Home: Location, other than a hospital or other facility, where the patient receives care in a private residence.
12
Urgent Care Facility: Location, distinct from a hospital emergency department, an office, or a clinic, whose purpose is to diagnose
and treat illness or injury for unscheduled ambulatory patients seeking immediate medical attention.
20
Inpatient Hospital: A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (surgical and nonsurgical), and
rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.
21
Outpatient Hospital: A portion of a hospital which provides diagnostic, therapeutic (surgical and nonsurgical), and rehabilitation
services to sick or injured persons who do not require hospitalization or institutionalization.
22
Emergency Room—Hospital: A portion of a hospital where emergency diagnosis and treatment of illness or injury is provided.
23
Ambulatory Surgical Center: A freestanding facility, other than a physician’s office, where surgical and diagnostic services are
provided on an ambulatory basis.
24
Skilled Nursing Facility: A facility which primarily provides inpatient skilled nursing care and related services to patients who require
medical, nursing, or rehabilitative services but does not provide the level of care or treatment available in a hospital.
31
Nursing Facility: A facility which primarily provides to residents skilled nursing care and related services for the rehabilitation of
injured, disabled, or sick persons or, on a regular basis, health-related care services above the level of custodial care to other than
individuals with intellectual disabilities.
32
Federally Qualified Health Center: A facility located in a medically underserved area that provides Medicare beneficiaries preventive
primary medical care under the general direction of a physician.
50
Rural Health Clinic: A certified facility which is located in a rural, medically underserved area that provides ambulatory primary
medical care under the general direction of a physician.
72
Not all-inclusive; please see full list in Current Procedural Terminology® or Chapter 26, Completing and Processing Form CMS-1500 Data Set, of the Medicare Claims Processing Manual.
a
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3
Documenting Abdominal Pain or Tenderness
This article continues our focus on diagnoses commonly
reported in pediatrics and the elements of documentation
that support code selection using International Classification
of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).
Although the transition to use of the ICD-10-CM code set has been delayed beyond the previously published date of
October 1, 2014, to no earlier than October 1, 2015, it is
important to take advantage of the extended opportunity to prepare for this pending transition.
This article focuses on the classification of abdominal and
pelvic pain. These symptoms have often been reported with
nonspecific International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) codes (eg, code
789.00 is reported for abdominal pain even though a specific
site of pain has been identified), and it may be helpful to
review the elements of documentation that support specific
code selection for abdominal pain and tenderness.
Chapter 18 of ICD-10-CM includes codes R00–R99 for
signs and symptoms. The ICD-10-CM Official Guidelines
for Coding and Reporting provide specific instruction for
reporting symptoms such as abdominal pain.
• Codes for signs and symptoms are reported when no
related definitive diagnosis has been established at the
time of an encounter.
• A sign or symptom that is routinely associated with a
diagnosed condition is not separately reported.
• A symptom that is not routinely associated with a definitive diagnosis may be separately reported.
Sequence the definitive diagnosis code first.
Example
A patient with pain in the right lower quadrant is seen at an
urgent care clinic. The physician documents rebound tenderness, right lower quadrant, possible appendicitis. The patient
is sent to the emergency department for further workup. The
same physician (or a physician of the same group and specialty) does not provide care at the hospital. The diagnosis at
the time of the clinic encounter (eg, rebound tenderness of
the right lower quadrant) is reported in conjunction with the
appropriate procedure code for the evaluation and management (E/M) service. (Appendicitis documented as possible
would not be reported because the guidelines for ICD-10-CM
4
do not allow reporting of uncertain diagnoses for physician
services.)
If, however, the same physician or a physician of the same
group and specialty provides observation or hospital care on
the same date and it is established that the abdominal tenderness is a symptom of a more specific diagnosis, only the code
for the definitive diagnosis would be reported in conjunction
with the procedure code representing the combined E/M
services provided on that date.
Note: Colic is reported based on the age of the patient. A
documentation of colic in an adult or child older than 12 months
is reported as generalized abdominal pain. Colic in an infant is
reported with code R10.83, colic. A diagnosis of renal colic is
reported with code N23.
Like ICD-9-CM, ICD-10-CM includes separate codes for
abdominal pain and abdominal tenderness. In addition,
rebound tenderness is separately classified in ICD-10-CM,
allowing for a more specific description of the patient’s
symptoms and, in some cases, better depicting the necessity
of additional workup. Pain, tenderness, and rebound tenderness are further characterized by the generalized or localized
site of discomfort. The Table shows ICD-10-CM codes for
pain and tenderness by site.
2014 ICD-10-CM Codes for Abdominal Pain and Tenderness
Pain NOS
Tenderness
Rebound
Tenderness
Epigastric
R10.13
R10.816
R10.826
Generalized, severe
(acute abdomen)
R10.0
See pain
See pain
Generalized, not
severe
R10.84
R10.817
R10.827
Left upper quadrant
R10.12
R10.812
R10.822
Left lower quadrant
R10.32
R10.814
R10.824
Pelvic and perineal
R10.2
See pain
See pain
Periumbilical
R10.33
R10.815
R10.825
Right upper quadrant
R10.11
R10.811
R10.821
Right lower quadrant
R10.31
R10.813
R10.823
Site
Abbreviation: NOS, not otherwise specified.
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Adaptive Behavior Assessments and Treatment
Current Procedural Terminology (CPT®) Category III codes
are codes assigned on a temporary basis for procedures and
services that do not yet meet the requirements for assignment
of a CPT Category I code. Category III codes are released
online twice per year (typically January and July) with implementation dates set for 6 months later. A group of new codes
for adaptive behavior assessment and treatment were released
January 1, 2014, and supplemented on March 1, 2014, with
implementation dates for these codes set for July 1, 2014. These
codes represent the services of behavior identification assessments, follow-up assessments, and adaptive behavior treatment
such as those that may be provided to a patient with an autism
spectrum disorder (ASD). Patients may present with deficient
adaptive or maladaptive behaviors (eg, impaired social skills
and communication deficits, destructive behaviors, additional
functional limitations secondary to maladaptive behaviors).
For full information on these codes, please see the current list
of CPT Category III codes at https://www.ama-assn.org/ama/
pub/physician-resources/solutions-managing-your-practice/
coding-billing-insurance/cpt/about-cpt/category-iii-codes.page.
Behavior identification assessments and adaptive behavior
treatment are reported based on direct face-to-face provision
of services by a physician or other qualified health care professional or by a technician or technicians working under the
direction of a physician or other qualified health care professional. Codes describe services to single patients, guardians
and caregivers (without the patient present), multiple patients,
and multiple family groups. When providing these services,
it is important to carefully review the code descriptors and
parenthetic instructions for reporting each code.
Table 1 includes a list of the adaptive behavior assessment and
treatment codes. As per CPT convention, codes preceded by a
+ (plus) are add-on codes always reported in conjunction with
a code for a related primary service. Add-on codes are used to
indicate additional intra-service work by the same practitioner
on the same date and would not be reported alone, for services on a date when no primary service was provided, or
when a physician or practitioner of another group practice
has provided the primary service.
Table 1. 2014 Codes for Behavior Identification Assessment and Adaptive Behavior Treatment
0359T
Behavior identification assessment, by the physician or other qualified health care professional, face-to-face with patient and
caregiver(s), includes administration of standardized and non-standardized tests, detailed behavioral history, patient observation
and caregiver interview, interpretation of test results, discussion of findings and recommendations with the primary guardian(s)/
caregiver(s), and preparation of report
0360T
Observational behavioral follow-up assessment, includes physician or other qualified health care professional direction with
interpretation and report, administered by one technician; first 30 minutes of technician time, face-to-face with the patient
+0361T
0362T
Exposure behavioral follow-up assessment, includes physician or other qualified health care professional direction with
interpretation and report, administered by physician or other qualified health care professional with the assistance of one
or more technicians; first 30 minutes of technician(s) time, face-to-face with the patient
+0363T
0364T
Adaptive behavior treatment by protocol, administered by technician, face-to-face with one patient; first 30 minutes of
technician time
+0365T
0366T
Group adaptive behavior treatment by protocol, administered by technician, face-to- face with two or more patients;
first 30 minutes of technician time
+0367T
0368T
Adaptive behavior treatment with protocol modification administered by physician or other qualified health care professional with one patient; first 30 minutes of patient face-to-face time
+0369T
0370T
Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional
(without the patient present)
0371T
Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care
professional (without the patient present)
0372T
Adaptive behavior treatment social skills group, administered by physician or other qualified health care professional
face-to-face with multiple patients
0373T
Exposure adaptive behavior treatment with protocol modification requiring two or more technicians for severe maladaptive
behavior(s); first 60 minutes of technicians’ time, face-to-face with patient
+0374T
each additional 30 minutes of technician time, face-to-face with the patient (List separately in addition to code for primary service)
each additional 30 minutes of technician(s) time, face-to-face with the patient (List separately in addition to code for primary procedure)
each additional 30 minutes of technician time (List separately in addition to code for primary procedure)
each additional 30 minutes of technician time (List separately in addition to code for primary procedure)
each additional 30 minutes of patient face-to-face time (List separately in addition to code for primary procedure)
each additional 30 minutes of technicians’ time, face-to-face with patient (List separately in addition to code for primary procedure)
(continued on page 7)
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5
QA
&
brought to you by the AAP Coding Hotline
With the latest delay of the transition to International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM), some physicians are saying that
the United States should just wait and transition to International Classification of
Diseases, 11th Revision (ICD-11). Is a transition to ICD-11 something that will take
place within the next few years?
Currently, the World Health Organization (WHO) is working on the 11th revision of the
International Classification of Diseases and indicates plans to present ICD-11 to the World
Health Assembly in May 2017. As was the case with ICD-10-CM, it is expected to take 5 to 6
years after the WHO release of ICD-11 for development and testing of a clinical modification
for use in the United States. In its 2009 final rule adopting ICD-10-CM as a replacement of
International Classification, Ninth Revision, Clinical Modification (ICD-9-CM) for diagnosis
coding, the US Department of Health and Human Services noted that had ICD-11 been
released by WHO in 2014, the earliest projected date to begin rule making for implementation of a US clinical modification of ICD-11 would be 2020. With presentation of ICD-11
delayed to at least 2017, and the United States’ own history of delayed transitions, it is doubt-
ful that a move directly from ICD-9-CM to ICD-11 is an option. It is also notable that even
some of those who have opposed the schedule for ICD-10-CM transition acknowledge that
transition to ICD-10-CM is a necessary step toward adoption of a clinical modification
of ICD-11.
Given this, ICD-10-CM adoption is still likely, but the transition will take place no earlier
than October 1, 2015. It is recommended that physicians take advantage of the extended
time to continue preparations, including testing with payers when available, continued
focus on education and documentation to support code selection, and development of
tools and work flow (eg, coding resources, expanded superbill).
Our practice has questions about reporting split/shared services in the office.
Our coder says that she was told that the split/shared visit is not applicable in the
office setting. If this is true, how do we report services that combine the services
of our nonphysician practitioners (NPPs) and our physicians?
Reporting split/shared services in the office setting requires understanding the Medicare
terminology of split/shared visits versus incident-to services. Medicare defines a split/shared
service as an evaluation and management (E/M) service in which a physician and an NPP
from the same group practice each personally perform a medically necessary and substantive
portion of one or more face-to-face E/M encounters on the same date. (Current Procedural
Terminology® uses the term other qualified health care professional rather than NPP.) The
physician and the NPP must each document the portion of the service he or she provided
and sign and date the note. While this would seem to apply to any face-to-face E/M service,
Medicare further specifies that split/shared services in the physician office setting must also
meet the requirements for an incident-to service. Many private payers use the Medicare
policy as their own.
In essence, incident-to requirements override split/shared billing in the office setting.
Incident-to requirements include all of the following:
• The service must be a continuation of a plan of care established by the patient’s physician
(not a new patient, new problem, or change of plan).
• The service must take place under direct physician supervision with the supervising
physician present in the office suite (but not necessarily in the room with the patient) at
the time of service.
• The service must be within the scope of practice allowed by state regulations for the
health care professional providing the service.
• The NPP (other qualified health care professional) must be an employee of or contracted
to work for the physician practice.
(continued on page 8)
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Oral Health Services Update
Oral health risk assessment is a universal preventive service
recommendation at the 12-, 18-, 24-, and 30-month and
3- and 7-year visits. Selective screening of oral health is
recommended at the 6- and 9-month visits. Many Medicaid
programs have established specific payment policy for oral
health risk assessment, with most separately paying for application of fluoride varnish (may be limited to children younger
than 3 years). Payers may require specific codes for reporting
these services in addition to the code for a well-child visit.
diagnosis and treatment. Currently, the application of fluoride
varnish is mostly reported with code D1208, topical application of fluoride. This may change in 2015. The February 2014
American Medical Association CPT Editorial Summary of
Panel Actions indicates the CPT Editorial Panel accepted a
new code to report application of fluoride varnish. The actual
code and details for reporting will be available after release
of CPT 2015; new codes are not assigned and are subject to
change until just prior to publication.
Often, the services may be reported with codes from the
Code on Dental Procedures and Nomenclature (CDT). Other
payers may require Current Procedural Terminology (CPT®)
code 99429 (unlisted preventive medicine service) with a
Healthcare Common Procedure Coding System level of
care modifier (eg, U5, Medicaid level of care 5, as defined
by each state).
Please verify each payer’s reporting requirements before
assigning codes for your services because other codes may be
required. State information and a resource map for children’s
oral health services can be found at www2.aap.org/oralhealth/
State.html. A link from this page will open a Caries Prevention
Services Reimbursement Table, which provides additional
state-specific information. An Oral Health Coding Fact Sheet
for Primary Care Physicians is also available from the Coding
at the AAP Web site (www.aap.org/coding). Refer to the
“Recommendations for Preventive Pediatric Health Care”
(www.aap.org/periodicityschedule) for more information
on preventive oral health recommendations.
Two new codes were added to CDT in 2013. Codes D0190
and D0191 describe pre-diagnostic services of screening to
determine an individual’s need to be seen by a dentist for
diagnosis or a limited clinical inspection that is performed
to identify possible signs of oral or systemic disease, malformation, or injury, and the potential need for referral for
Adaptive Behavior Assessments and Treatment (continued from page 5)
For codes reported based on time, the time is met when the
By reporting Category III codes for adaptive behavior assessmidpoint is passed. Therefore, a code for the first 30 minutes ment and treatment, physicians and other practitioners can
of service may be reported for 16 to 45 minutes of service. An
help show the progression of these services from that repreadd-on code for each additional 30 minutes would be reported
sented by Category III codes to services meeting Category I
for each additional increment of up to 30 minutes. Each minute service criteria (Table 2).
is counted only once whether one or more individuals are
Table 2. CPT Category I Code Criteriaa
involved in providing the individual service.
Although these codes present new opportunities for reporting
services to the patients who need them, Category III codes are
not assigned relative value units (RVUs) and individual payers
will determine coverage policy and payment values. Because
Category III codes may represent emerging technology or
services with which the payer is unfamiliar, the physician has
an opportunity to educate the payer to the service’s value in
accommodating appropriate payment for codes which otherwise do not have RVU assignment. When ordering or providing
these services, it is recommended to contact the payer for a copy
of its written coverage and payment policies for these services,
with special attention to any necessary prior authorization or
limitations based on provider network or number of services
within a specific period. (Note that although some states do
mandate coverage for behavioral therapy treatment for patients
with a diagnosis of an ASD, benefit limitations may apply.)
• The procedure or service is performed by many physicians or other qualified health care professionals across the United States.
• The procedure or service is performed with frequency consistent with the intended clinical use (ie, a service for a common condition should have high volume, whereas a service commonly performed for a rare condition may have low volume).
• The procedure or service is consistent with current medical practice.
• The clinical efficacy of the procedure or service is documented in literature that meets the requirements set forth in the CPT code change application.
Abbreviation: CPT, Current Procedural Terminology.
a
Please see full information on CPT code categories in the CPT manual or at
https://www.ama-assn.org/ama/pub/physician-resources/solutions-managingyour-practice/coding-billing-insurance/cpt/applying-cpt-codes.page.
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7
aappediatric
codingnewsletter
Q & A (continued from page 6)
™
Consulting Editors
Cindy Hughes, CPC, CFPC, PCS
American Academy of Pediatrics
Department of Marketing and
Publications Staff
Marie Mindeman
Maureen DeRosa, MPA
American Medical Association
Director, Department of Marketing CPT Editorial Research and and Publications
Development
Mark Grimes
Director, Division of Product Staff Editors
Development
Becky Dolan, MPH, CPC, CPEDC
Alain Park
Teri Salus, MPA, CPC, CPEDC
Senior Product Development Editor
Linda Walsh, MAB
Mark Ruthman
Manager, Electronic Product Development
Editorial Board
Sandi King, MS
Edward A. Liechty, MD, Editor
Director, Division of Publishing and Margie C. Andreae, MD, Chairperson,
Production Services
Committee on Coding and
Jason Crase
Nomenclature
Manager, Editorial Services
Joel F. Bradley, MD
Leesa Levin-Doroba
David M. Kanter, MD, CPC
Manager, Publishing and Production Steven E. Krug, MD
Services
Jeffrey F. Linzer Sr, MD
Linda Diamond
Richard A. Molteni, MD
Manager, Art Direction and Production
Julia M. Pillsbury, DO
Julia Lee
Jana Stockwell, MD
Director, Division of Marketing and Sales
Sanjeev Y. Tuli, MD
Marirose Russo
Brand Manager, Practice Management and Professional Publications
Based on this, an E/M service provided in part by a physician
and in part by an NPP in the office setting that does not meet
incident-to guidelines (eg, patient has a new problem) would
be reported as a service by the NPP or, if the payer allows, by the physician based on the level of service supported by his
or her documentation. (The physician may include the past, family, and social history and review of systems documented
by the patient, auxiliary staff, or an NPP if the physician supplements or confirms the information.) Incident-to requirements do not apply in the facility setting (eg, inpatient, emergency
department). Private payers may interpret this policy differently,
allowing the physician to report a shared E/M service in the
office. It is advisable to learn individual payers’ policies prior to billing.
What is the appropriate ICD-9-CM code for pseudo-
gynecomastia? The physician notes she will recheck at the next annual visit.
ICD-9-CM code 611.1, hypertrophy of breast, would be appropriate for pseudogynecomastia and gynecomastia. After the transition to ICD-10-CM, report code N62, hypertrophy of breast.
Copyright © 2014 American Academy of Pediatrics. CPT is copyright © 2013
American Medical Association. All Rights Reserved.
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constitutes endorsement by AAPC of the publication, content, or publication
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The recommendations in this publication do not indicate an exclusive course
of treatment or serve as a standard of medical care. Variations, taking into
account individual circumstances, may be appropriate.
Note: Brand names are for informational purposes only. Inclusion in this
newsletter does not imply endorsement. The American Academy of Pediatrics
does not recommend any specific brand of products or services.
Vignettes are provided to illustrate correct coding applications and are not
intended to offer advice on the practice of medicine.
AAP Pediatric Coding Newsletter™ Volume 9, Number 10, ISSN 1934-5135 (Print),
ISSN 1934-5143 (Online) is published monthly by the American Academy of
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8
Coming Next Month
1 Observation Care Services: CPT or Medicare
2 Pupillometry in Clinical Care: New Procedure Code 0341T
3 Q&A
4 Reporting the National Drug Code: A Refresher
5 Transitioning to 10: Documenting Diabetes Mellitus
aap pediatric coding newsletter coding.aap.org July 2014
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