Abbreviations AAP American Academy of Pediatrics ACO Accountable care organization AMA American Medical Association CF Conversion factor CMS Centers for Medicare & Medicaid Services COCN AAP Committee on Coding and Nomenclature CPT Current Procedural Terminology DHHS Department of Health and Human Services E/M Evaluation and management ED Emergency department GPCIs Geographic practice cost indices HCPCS Healthcare Common Procedure Coding System HIPAA Health Insurance Portability and Accountability Act of 1996 HPI History of present illness ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-CM International Classification of Diseases, 10th Revision, Clinical Modification NCCI National Correct Coding Initiative NPI National Provider Identifier OIG Office of Inspector General PATH Physicians at Teaching Hospitals PE Practice expense PFSH Past, family, and social history PLI Professional liability insurance RBRVS Resource-Based Relative Value Scale ROS Review of systems RUC American Medical Association/Specialty Society Relative Value Scale Update Committee RVU Relative value unit SOAPM AAP Section on Administration and Practice Management SoPPe AAP Section on Perinatal Pediatrics
Coding for Pediatrics 2015 A Manual for Pediatric Documentation and Payment For use with AMA CPT 2015 20th Edition Author Committee on Coding and Nomenclature (COCN) American Academy of Pediatrics Edward A. Liechty, MD, Editor Cindy Hughes, CPC, CFPC, Consulting Editor Becky Dolan, MPH, CPC, CPEDC, Staff Editor American Academy of Pediatrics 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019
AAP Department of Marketing and Publications Staff Maureen DeRosa, MPA Director, Department of Marketing and Publications Mark Grimes Director, Division of Product Development Alain Park Senior Product Development Editor Sandi King, MS Director, Division of Publishing and Production Services Jason Crase Manager, Editorial Services Leesa Levin-Doroba Manager, Publishing and Production Services Peg Mulcahy Manager, Graphic Design and Production Houston Adams Digital Content and Production Specialist Julia Lee Director, Division of Marketing and Sales Marirose Russo Brand Manager, Practice Management and Professional Publications ISBN: 978-1-58110-880-4 ebook: 978-1-58110-900-9 ISSN: 1537-324X MA0720 Quantity prices on request. Address all inquiries to American Academy of Pediatrics Division of Marketing and Sales 141 Northwest Point Blvd Elk Grove Village, IL 60007-1019 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. Products are included for informational purposes only. Inclusion in this publication does not imply endorsement by the American Academy of Pediatrics. Copyright 2015 American Academy of Pediatrics. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Printed in the United States of America. CPT copyright 2014 American Medical Association (AMA). All rights reserved. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. CPT is a registered trademark of the AMA. This publication has prior approval of the American Academy of Professional Coders (AAPC) for 4.0 continuing education units. Granting of this approval in no way constitutes endorsement by AAPC of the publication content or publication sponsor. 11-35J
iii 2014 2015 Committee on Coding and Nomenclature (COCN) Richard A. Molteni, MD, Chairperson Margie C. Andreae, MD Joel F. Bradley, MD Eileen D. Brewer, MD David M. Kanter, MD, CPC Steven E. Krug, MD Edward A. Liechty, MD Jeffrey F. Linzer Sr, MD Julia M. Pillsbury, DO Sanjeev Y. Tuli, MD Liaison Samuel D. Smith, MD American Pediatric Surgical Association 2014 2015 AAP Coding Publications Editorial Advisory Board Edward A. Liechty, MD, Editor in Chief Margie C. Andreae, MD Joel F. Bradley, MD Jamie Calabrese, MD, CPC David M. Kanter, MD, CPC Steven E. Krug, MD Jeffrey F. Linzer Sr, MD Richard A. Molteni, MD Julia M. Pillsbury, DO Jana Stockwell, MD Sanjeev Y. Tuli, MD AAP Staff Becky Dolan, MPH, CPC, CPEDC Teri Salus, MPA, CPC, CPEDC Linda Walsh, MAB
iv Disclaimer Every effort has been made to include the new and revised 2015 Current Procedural Terminology (CPT ); International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM); International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM); and Healthcare Common Procedure Coding System (HCPCS) codes, their respective guidelines, and other revisions that might have been made. Due to our publishing deadlines and the publication date of the American Medical Association CPT, additional revisions and/or additional codes may have been published subsequent to the date of this printing. It is the responsibility of the reader to use this manual as a companion to the CPT, ICD-9-CM, ICD-10-CM, and HCPCS publications. Vignettes are provided throughout this publication to illustrate correct coding applications. They are not intended to offer medical advice on the practice of medicine. ICD-10-CM codes are used for reference purposes only. Do not report ICD-10-CM codes until its published implementation date. Further, it is the reader s responsibility to access the American Academy of Pediatrics Web site (www.aap.org/cfp) routinely to find any corrections due to errata in the published version.
v Copyright Acknowledgment Current Procedural Terminology (CPT ) is a listing of descriptive terms and 5-digit numeric identifying codes and modifiers for reporting medical services and procedures performed by physicians. This presentation includes only the CPT descriptive terms, numeric identifying codes, and modifiers for reporting medical services and procedures that were selected by the American Academy of Pediatrics (AAP) for inclusion in this publication. The inclusion of a CPT service or procedure description and its code number in this publication does not restrict its use to a particular specialty group. Any procedure or service in this publication may be used to report the services provided by any qualified physician or, when appropriate, other qualified health care professional. The American Medical Association (AMA) and the AAP assume no responsibility for the consequences attributable to or related to any use or interpretation of any information or views contained in or not contained in this publication. Any 5-digit numeric CPT code, service descriptions, instructions, and/or guidelines are copyright 2014 (or such other date of publication of CPT as defined in the federal copyright laws) AMA. All rights reserved. The most current CPT is available from the AMA. No fee schedules, basic unit values, relative value guides, conversion factors or scales, or components thereof are included in CPT.
vii Contents Foreword... ix Acknowledgments... xi Chapter 1 New and Revised CPT and ICD-9-CM Codes for 2015... 1 Chapter 2 Diagnosis Coding: ICD-9-CM and ICD-10-CM...17 Chapter 3 Modifiers and Coding Edits... 33 Chapter 4 Evaluation and Management Documentation and Coding Guidelines: Incident-To, PATH Guidelines, and Scope of Practice Laws...61 Chapter 5 Preventive Services...89 Chapter 6 Evaluation and Management Services in the Office, Outpatient, Home, or Nursing Facility Setting...115 Chapter 7 Perinatal Counseling and Care of the Neonate...145 Chapter 8 Noncritical Hospital Care...163 Chapter 9 Emergency Department Services... 189 Chapter 10 Critical and Intensive Care...211 Chapter 11 Evolving Evaluation and Management and Nonphysician Services...241 Chapter 12 Common Procedures and Non Evaluation and Management Medical Services... 269 Chapter 13 Category II CPT Codes Pay for Performance Measures and Category III CPT Codes Emerging Technologies...321 Chapter 14 Preventing Fraud and Abuse: Compliance, Audits, and Paybacks... 337 Chapter 15 The Business of Medicine: From Clean Claims to Correct Payment and Emerging Payment Methodologies... 355
viii Chapter 16 Continuing Education Units (CEUs) for American Academy of Professional Coders Accreditation...375 Appendices NOTE: Appendices preceded by access code AAPCFP20. can be located online at www.aap.org/cfp, Appendix A 1995 Documentation Guidelines for Evaluation and Management Services... 385 1997 Documentation Guidelines for Evaluation and Management Services... 395 Physicians at Teaching Hospitals (PATH) Guidelines (online only)... 429 MLN Matters SE0441 CMS Incident-To Requirements (online only)... 429 Appendix B: Your Coding Toolkit Figure B-1. CPT Coding Change Request Form (online only)... 430 Figure B-2. Commonly Used ICD-9-CM Codes Crosswalked to ICD-10-CM Codes... 431 Figure B-3. AAP Documentation Forms (online only)... 437 Figure B-4. FAQ: Immunization Administration (online only)... 437 Figure B-5. Vaccine Products (online only)... 437 Figure B-6. Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines... 438 Figure B-7. Chronic Care Management Worksheet... 441 Figure B-8. Care Plan Oversight Encounter Worksheet... 442 Figure B-9. Sample Denial Tracking Tool... 443 Figure B-10. Claim Correction Form (online only)... 444 Figure B-11. Sample Appeal Letter (online only)... 444 Figure B-12. Effective Health Plan Appeals: The Ins and Outs... 445 Figure B-13. FAQ: Alternative Payment Methodologies (online only)... 450 Figure B-14. Marshfield Audit Tool (online only)... 450 Figure B-15. Coding Fact Sheets (online only)... 450 Appendix C Asthma Clinical Performance Measures (online only)... 451 Appendix D 2015 Pediatric Coding Resources Exclusively From the AAP... 452 Indices Subject Index... 453 Code Index... 466
ix Foreword The American Academy of Pediatrics (AAP) is pleased to publish this, the 20th edition of Coding for Pediatrics an instructional manual and reference tool for use by primary care pediatricians, pediatric subspecialists, and others involved in the provision of care to children. The purpose of this manual is to support the delivery of quality care to children by providing the pediatric practitioner with the knowledge to best support appropriate business practices. Many changes have been made to this edition, including updating the 2015 Current Procedural Terminology (CPT ) codes with guidelines for their application, a new chapter on coding for perinatal counseling and care of the newborn, and a new chapter on coding for nontraditional evaluation and management services and nonphysician services. For several years, Coding for Pediatrics has included information on International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) in anticipation of the transition, which was scheduled for October 1, 2014. On April 1, 2014, this transition was delayed to October 1, 2015, by the enactment of the Protecting Access to Medicare Act of 2014. In response to this delay, Coding for Pediatrics 2015 includes ICD-9-CM and ICD-10-CM codes in clinical vignettes, providing ICD-10-CM education in anticipation of the pending transition. Coding tips include key documentation elements to support specific and accurate ICD-10-CM code selection. In addition, the AAP is pleased to provide Coding for Pediatrics 2015 as an ebook. Any corrections that may be necessary subsequent to the publication of the manual will be available to readers of Coding for Pediatrics 2015 by accessing www.aap.org/cfp. Coding for Pediatrics 2015 does not replace CPT, ICD-9-CM, ICD-10-CM, or Healthcare Procedure Coding System (HCPCS); rather, it supplements those manuals. Every effort has been made to include the 2015 codes and their respective guidelines; however, revised codes and/or guidelines may have been published subsequent to the date of this printing. Updates to this manual will be posted on the Coding for Pediatrics Web site (www.aap. org/cfp). The AAP actively works with the American Medical Association (AMA) CPT Editorial Panel and the AMA/Specialty Society Relative Value Scale Update Committee (RUC) to develop pediatric specialty codes and assign them appropriate relative value units. Since 1995, the AAP has contributed to the process that evaluates and reviews changes to the Medicare Resource-Based Relative Value Scale (RBRVS). Pediatricians have been actively involved in the AMA RUC Practice Expense Advisory Committee to review direct practice expenses for all existing codes. As importantly, the AAP is represented on the AMA CPT Editorial Advisory Panel and on the ICD-10-CM Editorial Advisory Board. The AAP continues to be involved in all areas of payment. The AAP Committee on Coding and Nomenclature oversees all areas of coding as they relate to pediatrics, including CPT procedure coding, ICD-9-CM and ICD-10-CM diagnosis coding, and the valuation of CPT services through the Medicare RBRVS. The AAP will continue to request new code changes and attempt to expeditiously notify membership of changes through various means. The AAP Pediatric Coding Newsletter a monthly newsletter available in print and online provides members and their office personnel with up-to-date coding and payment information. The newsletter and other online resources can be accessed through the AAP newsletter Web site (http://coding.aap.org). Other resources include coding seminars presented at the AAP National Conference & Exhibition; webinars sponsored by the AAP (www.aap.org/ webinars/coding); instructional materials in AAP News, including the Coding Corner; Pediatric Code Crosswalk: ICD-9-CM to ICD-10-CM and the forthcoming Pediatric
x ICD-10-CM: A Manual for Provider-Based Coding; and various quick reference cards. A list of these and other resources can be found in Appendix D of this manual. The use of these resources should provide the membership with the skills needed to report their services appropriately. The Division of Health Care Finance and Practice Improvement at the AAP headquarters stands ready to assist with problem areas not adequately covered in this manual. The AAP Coding Hotline can be accessed through e-mail at aapcodinghotline@aap.org.
xi Acknowledgments Coding for Pediatrics, 20th Edition, is the product of the efforts of many dedicated individuals. My work has been made immeasurably easier and the final edition dramatically improved by the dedicated work of my collaborators. First and foremost, I must thank Cindy Hughes, CPC, CFPC, consulting editor, for her professional input and particularly for her ongoing work to make it more user-friendly and readable, a goal she and I share. Additionally, I must thank the Committee on Coding and Nomenclature (COCN) support staff at the American Academy of Pediatrics (AAP), particularly Becky Dolan, MPH, CPC, CPEDC, staff editor, for her many excellent suggestions as well as for reviewing major portions of the project. Thank you also to Teri Salus, MPA, CPC, CPEDC, for her review of new Current Procedural Terminology (CPT ) codes and suggestions for changes to content. I would also like to thank the members of the COCN and the AAP Coding Publications Editorial Advisory Board. The members of those committees have each contributed extensive time in reviewing and updating content of the manual. I would like to particularly acknowledge those COCN members who have devoted their time and expertise to national committees, providing a breadth of knowledge not otherwise possible: Margie C. Andreae, MD, AAP representative to the American Medical Association/ Specialty Society Relative Value Scale Update Committee (RUC); Eileen D. Brewer, MD, AAP alternate RUC representative; Steven E. Krug, MD, AAP RUC advisor; Joel F. Bradley, MD, AAP CPT advisor and former CPT Editorial Panel member; Sanjeev Y. Tuli, MD, AAP alternate CPT advisor; Julia M. Pillsbury, DO, CPT Editorial Panel member; Jeffrey F. Linzer Sr, AAP International Classification of Diseases, 10th Revision, Clinical Modification Editorial Advisory Board representative and ICD-11 Pediatric Topic Advisory Group chairperson; and Richard A. Molteni, MD, former AAP CPT advisor and former CPT Editorial Panel member. I am most grateful to the invaluable input of the following AAP committees and individuals: the Committee on Medical Liability and Risk Management, specifically Stephan Paul, MD, JD, FAAP, and AAP staff Julie Ake, senior health policy analyst; the Private Payer Advocacy Advisory Committee, specifically Sue Kressly, MD, FAAP, and AAP staff Lou Terranova, senior health policy analyst; Samuel D. Smith, MD, liaison for the American Pediatric Surgical Association; and the Section on Perinatal Pediatrics coding trainers. I appreciate the information on emerging payment methodologies provided to me by Edward P. Zimmerman, director, AAP Department of Practice, and by the AAP Committee on Child Health Financing, particularly Thomas Long, MD, FAAP. This project would not have been completed were it not for the outstanding work of the AAP staff. In the Department of Marketing and Publications, Alain Park, senior product development editor; Jason Crase, manager of editorial services; Peg Mulcahy, manager of graphic design and production; Leesa Levin-Doroba, manager of publishing and production services; and Marirose Russo, brand manager for practice management and professional publications, deserve special recognition for their outstanding skill and dedication to this project. In the Division of Health Care Finance and Practice Improvement, I am especially appreciative of the support and professional expertise of Linda Walsh, MAB, division director, and AAP staff support to the AAP COCN, a dedicated advocate for all of us who provide medical care to children. Edward A. Liechty, MD Editor