Often, services provided to children with special health care needs (CSHCN) exceed the typical services provided to most patients in primary care settings, and most of these are described by existing CPT codes. However, they are used much less frequently than the more common codes and some insurers do not recognize or reimburse for these codes appropriately. Similarly, the diagnoses of many CSHCN are uncommon, or rare, and may not be specifically described in ICD-9-CM or, if they are, the codes may not be readily recognized by our billing/coding personnel or by insurers. Nevertheless, detailed, accurate, and complete coding provides the best available methodology to communicate to insurers and other administrative agencies the nature of the patients we treat and the services we provide. Codes that are used appropriately are more likely to gain recognition and reimbursement than codes that are never used. The following are examples of CPT codes for services that are expected to be provided within Medical Homes but that are often not coded for correctly or compensated properly:
- Hearing screening, pure tone (92551),
- Central Nervous System Assessments (developmental and emotional/behavioral) (96110-96127)
- Services after hours, emergency, etc. (99050-99058)
- Special Reports (99080)
- Collect/interpret physiologic data, ≥30 min. (99091)
- Vision screening, quantitative, bilateral (99173)
- Care plan oversight services, home (99339-99340)
- Home visits (99341-99350)
- Prolonged physician services, face-to-face (99354-99357)
- Prolonged physician services, not face-to-face (99358-99359)
- Team conferences (99361-99362)
- Telephone calls (99371-99373)
- Care plan oversight services, home health (99374-99375)
- Care plan oversight services, hospice (99377-99378)
- Care plan oversight services, nursing facility (99379-99380)
- Counseling and/or risk factor reduction intervention codes for individuals (99401-99404) or for groups (99411-99412)
- Complex chronic care management services, per month (99487, 99489)
- Chronic care management services, per month (99490)
- -25 modifier, used when the service significantly exceeds the usual service provided for that code (e.g., billing a preventive medicine visit code, 99381-99397, plus a 99214-25 for the added time dealing with the child's spasticity, seizure disorder, and feeding problems)
These guidelines are complex and lengthy. We have tried to summarize the documentation criteria for office Evaluation and Management (E&M) codes in the one-page CPT Documentation Guide ( 45 KB).
Each ICD-9 code will have a minimum of three numerals (V codes have a V and two numerals; E codes have an E and three numerals), most with an additional digit or two following a decimal point, for example "Down syndrome" is coded by 758.0, whereas "other conditions due to sex chromosome abnormalities" is coded by 758.81.
The most specific code(s) possible should be used, for example, in the table below of a category of congenital heart disease, a "complete transposition of the great vessels" requires two digits following the decimal point to most specifically describe it.
- 745 Bulbus cordis anomalies and anomalies of cardiac septal closure
- 745.0 Common truncus
- 745.1 Transposition of great vessels
- 745.10 Complete transposition of great vessels
- 745.11 Double outlet right ventricle
- 745.12 Corrected transposition of great vessels
- 745.19 Other
- 745.2 Tetralogy of Fallot
- 745.3 Common ventricle
- 745.4 Ventricular septal defect
- 745.5 Ostium secundum type atrial septal defect
- 745.6 Endocardial cushion defects
- 745.60 Endocardial cushion defect, unspecified type
- 745.61 Ostium primum defect
- 745.69 Other
- 745.7 Cor biloculare
- 745.8 Other
- 745.9 Unspecified defect of septal closure
ICD-9 codes are organized in two ways: first alphabetically by diagnosis and second numerically by code (tabular list). In general, when looking up a diagnosis, you should first look in the alphabetic list for the diagnosis, symptom, etc., and then look up that code in the tabular section to confirm its accuracy and to peruse subcodes and surrounding codes to assure it specificity and level of detail.
AAP Committee on Coding and Nomenclature
Updates of new and revised CPT and ICD-9-CM coding.
Care Coordination Tool Kit 2004 ( 2.1 MB)
Information about proper use of codes, documentation, office tips, and more from the Center for Infants and Children with Special Needs.
Coding Publications from the AAP
Books, quick references, how-to guides for CPT and ICD9 coding, specific to pediatrics.
Medical Home Practice-Based Care Coordination Workbook
Tools and information for improving care coordination from the Center for Medical Home Improvement.
|Lead Author:||Chuck Norlin, MD - 4/2008|
|Content Last Updated:||1/2015|