Fall brings new color and a transition to the new year ahead. The Physicians’ Current Procedural Terminology (CPT®) world has its own change of season—a change of color for the American Medical Association (AMA) manual (from red to yellow this year) to herald new codes of great importance in the year ahead. Like leaves that fall from trees and cover our lawns, old codes need to be swept from our superbills. This issue of Pediatric Coding Companion presents coding changes for 2005; we encourage you to take time to review your superbill (and perhaps your fee schedule in general), discard CPT (as well as diagnosis) codes that have been deleted, and add new codes that will best serve the needs of your practice. Because diagnosis codes (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM]) were released last summer and implemented on October 1, 2004, only CPT code changes are discussed in this article. Just as the diagnosis codes were implemented on an earlier date, all new CPT codes were effective, by Health Insurance Portability and Accountability Act standards, on January 1, 2005. The American Academy of Pediatrics (AAP) publication Coding for Pediatrics has been revised for 2005 and serves as the best reference for pediatric coding.Like 2004, critical care codes contain changes for the upcoming year. Although there are no new codes to incorporate, existing inpatient critical care codes for global services provided to neonates (99295–99296) and children (99293–99294) have undergone a minor but noteworthy editorial change in the age of the patient. Neonates are defined in World Health Organization literature and ICD-9-CM as being 28 days or younger. To provide consistency and eliminate confusion, the use of neonatal critical care codes is now limited to patients aged birth through 28 days, with pediatric critical care codes now beginning at 29 days and lasting through 24 months of age.Thus, in 2005, when you admit a 29-day-old neonate to critical care, use pediatric inpatient critical care code 99293 and not neonatal initial day code 99295, as you did in 2004. Similarly, on the day the baby receiving ongoing newborn critical care services (99296) becomes 29 days of age, the code reported for that day’s services will be 99294.(Subsequent care for neonates who require an intensive setting but who are not critically ill is reported using intensive low birth weight services codes [99298–99299] or subsequent hospital care codes [99231–99233].)Critical care codes also took center stage among evaluation and management (E/M) changes in 2004. Do not forget that the codes were revised to limit neonatal and pediatric critical care codes to use in the inpatient setting only. Hourly critical care codes (99291–99292) are used for all ages in the outpatient setting (eg, your office, emergency department) and all settings in which these very intensive services are provided for patients older than 24 months. The list of bundled services in inpatient neonatal and pediatric codes did not change for 2005. If you are using these codes, you must be familiar with the list of codes for procedures that are paid without separate billing. One exception to this is that procedures included in the bundled list but performed as part of the delivery room resuscitation can be billed separately (eg, endotracheal intubation). Documentation must reflect medical need for the procedure prior to actual admission to the neonatal intensive care unit. In addition, codes for attended delivery services (99436) or resuscitation (99440) also can be listed together with 99295.Note that the stringent definition of critically ill has not changed—patients require highly complex medical decision making and an illness or injury that is life threatening. As you would suspect, the care and condition that are required to report these codes must be well documented.What happens when pediatricians provide critical care services in an outpatient setting (usually the emergency department or, rarely, their offices)? Certainly these services take intense resources and should be reported as critical care services, not simply bundled into emergency department or office visit codes. The language in CPT makes it clear that the codes used for neonatal and pediatric critical care are for an inpatient setting only. When these services are performed in an outpatient setting, use existing hourly codes (99291–99292) and document the condition, care rendered, and time in minutes. If a patient is seen in an outpatient or inpatient location, receives an E/M service, then worsens and requires critical care, CPT allows the E/M service and critical care code to be reported on the same day.At last, a new set of codes has arrived to allow reporting of vaccines for children. Written for use with children younger than 8 years, these codes are reported when the patient or family receives counseling from the physician on vaccine risks and benefits. Creation of these codes will allow the recognition of physician work by the Centers for Medicare and Medicaid Services (CMS) in its 2005 Medicare Resource-Based Relative Value Scale (RBRVS) (see Table 1), thereby improving relative values. As with existing codes, these new codes distinguish between the first vaccine given at one encounter and each additional vaccine administered. Similarly, they also allow 2 codes for injections and 2 codes for oral or intranasal delivery. As always, these codes are reported along with the product code for the vaccine or toxoid given.So how are these new codes used? Beginning January 1, 2005, when vaccines are administered, ask yourself the following questions:If the answer to both is yes, the new codes more accurately report the service.Conversely, if the patient is 8 years or older, report existing codes 90471–90474, as appropriate. If the patient does not receive counseling from the physician, the existing codes are again used. Remember that when CPT uses the term physician, it also includes physician assistants and nurse practitioners who are working within their state scope of practice regulations.Coding for nurse-only vaccine visits means using the existing vaccine administration codes because the physician is not counseling the patient. If the nurse provides a significant E/M service above and beyond the work of vaccine administration, 99211 is the correct code, used along with the vaccine product code and 90471–90474. The nurse E/M service might include taking a history of present illness and vital signs, counseling the family above and beyond the usual questions families ask for such visits, or calculating doses of medications used to treat possible reactions. Nurse activities already included in the vaccine administration itself include presenting the Vaccine Information Statement, answering typical questions about the vaccine and past vaccine experience, the actual administration of the product, and the necessary charting. Documentation of all the services provided is required, and we recommend that the service be carried out under a physician-directed protocol and the chart be reviewed and signed by the physician after the visit.There was less activity concerning new vaccine product codes for 2005 than last year. Code 90656 was added for a preservative-free influenza vaccine for individuals 3 years and older. This accompanies the existing code for the preservative-free vaccine for children 6 to 35 months of age, 90655. New codes for conjugate meningococcal vaccine (90734); diphtheria, tetanus, and acellular pertussis (DTaP) vaccine for children older than 7 years (90715); and combination vaccine DTaP-Haemophilus influenzae type b (Hib)-poliovirus (IPV) (90698) all await Food and Drug Administration (FDA) approval of their respective vaccines and Advisory Committee for Immunization Practices guidelines for their use.Codes 94060 and 94070 for spirometry pre- and post-bronchodilator were revised to clarify that the medication itself is reported using the supply code (J code) or CPT code 99070. Also, the term evaluation was removed to avoid confusion over reporting E/M codes done at the same visit.Code 96111 incurs a coding change that resulted from a 2004 RBRVS Update Committee (RUC)-requested change to eliminate the “per hour” text of the descriptor. Because testing sessions typically last a little more than an hour, the code is revised as follows:Codes are added in 2005 for additional esophageal studies.For those pediatricians trained in multimodal treatments for pain, acupuncture codes are an important addition. They clarify whether electrical current is used and add time to the descriptors.Joining the existing codes for rapid antigen detection is one for respiratory syncytial virus.An addition in 2005, the anesthesia guidelines provide instruction for reporting conscious sedation when it is provided by a physician other than the one performing the primary procedure (the current conscious sedation codes are limited to use by the same physician who performs the procedure).When any physician other than the physician performing the procedure provides anesthesia services as specified in CPT guidelines (conscious sedation or otherwise), the anesthesia codes should be reported.There were no major changes to procedures that pediatricians use. Remember in 2004, starred codes ceased to exist. Procedures in this section no longer have the star (*) appended to designate the lack of a CPT surgical package. Readers are referred to the section in CPT to read about the CPT surgical package. Additionally, many surgical procedures will have an established Medicare global period of 0, 10, or 90 days. Services provided during a global period are already paid in the original code for the procedure itself; code 99024 can be reported to designate a service performed during this time but no charge is added (although x-ray film and supplies can be billed).Category I CPT codes are joined by a section of codes added to allow tracking of services for the purpose of performance improvement, known in CPT as Category II codes. They are not included to replace the usual codes used for billing, but will allow automated data capture and reduce chart abstraction work when performance activities are done. These codes are alphanumeric—a combination of 4 numbers followed by a letter (eg, 1234A). They are not valued in the RUC process and thus have no relative values in the RBRVS. Proposals for these codes are reviewed by the Performance Measures Advisory Group to the CPT Editorial Panel. New for 2005 is a format that organizes the codes into sections.Examples of new codes (patient history section) include 1000F, tobacco use, smoking, assessed, and 1001F, tobacco use, nonsmoking, assessed.Category II codes will provide the coding infrastructure for many “pay for quality” programs being implemented by forward-thinking payers and allow health plans to accrue data more easily for accreditation by entities such as the National Committee for Quality Assurance.These codes are relatively new to CPT and like Category I codes, resulted from the CPT-5 project to improve the coding system. This category of codes is for emerging technologies. Although the new and existing codes are found in the CPT text, they are actually released like vaccine product codes—twice a year (July 1 and January 1) via the AMA Web site (http://www.ama-assn.org/ama/pub/category/3885.html). Unlike Category II performance improvement codes, however, these can be used for billing, even though they will not usually appear in the Medicare RBRVS (with an exception—the CMS may provide a G code in the Healthcare Common Procedure Coding System [HCPCS] if it makes a favorable payment coverage decision). If the services these codes represent find FDA approval and/or experience significant or widespread use, they are likely to attain full Category I status in coming years. Thus, it is important to use these codes for reporting to payers as well as internal tracking within the practice. The following are new for 2005:2005 sees an expansion of CPT with the addition of 4 new appendices to enhance or clarify codes in the main section. (For reference, CPT modifiers are found in Appendix A.) The 4 new appendices are as follows:Spurred on by member requests, the AAP very actively participates in the CPT process. Two AAP members have or are now serving on the AMA CPT Editorial Panel, and the AAP has an advisor to CPT. These individuals, along with the Committee on Coding and Nomenclature and its excellent AAP staff from the Division of Health Care Finance and Practice, regularly solicit member ideas for new codes, develop new code proposals, and work with the AMA CPT Editorial Panel and other specialty societies to get codes implemented.Your role as a practicing physician is to develop the best clinical care model for your patients based on their needs and the best medical evidence. Once the best care model is defined, if codes do not exist that allow accurate reporting of (and hence payment for) your hard work, new codes or revised codes may be needed. Remember, while the existence of a CPT code does not guarantee payment for a service you provide, it is the first step, and one you must take in a non-capitated world before any health care dollars flow your way!The following are CPT activities planned or ongoing for 2006:
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