Coding for Pediatrics 2018

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Coding for Pediatrics 2018 A MANUAL FOR PEDIATRIC DOCUMENTATION AND PAYMENT 23rd Edition For Use With AMA CPT 2018 From Coding for Pediatrics 2018 23rd Ed: Downloaded on Dec 28 2017

1 Coding for Pediatrics 2018 A MANUAL FOR PEDIATRIC DOCUMENTATION AND PAYMENT 23rd Edition For Use With AMA CPT 2018 From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved. The indispensable how-to guide on pediatric coding. Covers CPT and ICD-10-CM with expert advice tips and guidelines.

2 Coding for Pediatrics 2018 A Manual for Pediatric Documentation and Payment For Use With AMA CPT rd 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 From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

3 ii American Academy of Pediatrics Publishing Staff Mark Grimes Director Department of Publishing Barrett Winston Senior Editor Professional/Clinical Publishing Leesa Levin-Doroba Production Manager Practice Management Jason Crase Manager Editorial Services Peg Mulcahy Manager Art Direction and Production Mary Lou White Chief Product and Services Officer/SVP Membership Marketing and Publishing Mary Jo Reynolds Marketing Manager Practice Publications Published by the American Academy of Pediatrics 141 Northwest Point Blvd Elk Grove Village IL Telephone: 847/ Facsimile: 847/ 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. Vignettes are provided to illustrate correct coding applications and are not intended to offer advice on the practice of medicine. Products are included for informational purposes only. Inclusion in this publication does not imply endorsement. The American Academy of Pediatrics does not recommend any specific brand of products or services. This publication has been developed by the American Academy of Pediatrics. The contributors are expert authorities in the field of pediatrics. No commercial involvement of any kind has been solicited or accepted in development of the content of this publication. Quantity prices on request. Address all inquiries to American Academy of Pediatrics Department of Membership Engagement Marketing and Sales 141 Northwest Point Blvd Elk Grove Village IL 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 (locate title at and click on Get Permissions; you may also fax the permissions editor at 847/ or permissions@aap.org). Printed in the United States of America CPT copyright 2017 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 M From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved. MA0832 ISBN: ebook: ISSN: X

4 iii 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 MBA CPC Steven E. Krug MD Edward A. Liechty MD Jeffrey F. Linzer Sr MD Linda Parsi MD MBA CPEDC CMOM CMC Julia M. Pillsbury DO Liaison Samuel D. Smith MD American Pediatric Surgical Association AAP Coding Publications Editorial Advisory Board Edward A. Liechty MD Editor in Chief Joel F. Bradley MD Jamie Calabrese MD CPC David M. Kanter MD MBA CPC Steven E. Krug MD Jeffrey F. Linzer Sr MD Jeanne Marconi MD Richard A. Molteni MD Linda Parsi MD MBA CPEDC CMOM CMC Julia M. Pillsbury DO Renee F. Slade MD Jana Stockwell MD Sanjeev Y. Tuli MD AAP Staff Becky Dolan MPH CPC CPEDC Teri Salus MPA CPC CPEDC Linda Walsh MAB From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

5 iv Disclaimer Every effort has been made to include the new and revised 2018 Current Procedural Terminology (CPT ); 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-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. Further it is the reader s responsibility to access the American Academy of Pediatrics Web site ( routinely to find any corrections due to errata in the published version. From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

6 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 2017 (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. From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

7 vi In Memoriam This edition of Coding for Pediatrics is dedicated to the life and memory of Edward Zimmerman former Director of the Department of Pediatrics at the American Academy of Pediatrics. He supported this work as a director and also brought his insight to the manual by contributing to the ongoing evolution of content particularly The Business of Medicine chapter. Ed was an advocate for children and pediatricians. Those who knew him remember him as a well-dressed gentleman who also was well-read. A voracious bookworm he often would gift books to others and urge them to read it forward. He will be missed. From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

8 vii Contents Foreword... ix Acknowledgments... x Chapter 1 New and Revised CPT Codes for Chapter 2 Diagnosis Coding: ICD-10-CM...19 Chapter 3 Modifiers and Coding Edits...37 Chapter 4 Evaluation and Management Documentation Guidelines...67 Chapter 5 Time-Based Coding Chapter 6 Preventive Services Chapter 7 Evaluation and Management Services in the Office Outpatient Home or Nursing Facility Setting Chapter 8 Managing Chronic and Complex Conditions Chapter 9 Pre-birth Counseling and Care of the Newborn Chapter 10 Noncritical Hospital Evaluation and Management Services Chapter 11 Emergency Department Services Chapter 12 Critical and Intensive Care Chapter 13 Telemedicine Chapter 14 Allied Health and Clinical Staff Services Chapter 15 Common Surgical Procedures and Sedation Chapter 16 Common Testing and Therapeutic Services From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

9 viii CONTENTS Chapter 17 Coding to Demonstrate Quality and Value Chapter 18 Preventing Fraud and Abuse: Compliance Audits and Paybacks Chapter 19 The Business of Medicine: Working With Current and Emerging Payment Systems Chapter 20 Continuing Education Units (CEUs) for American Academy of Professional Coders Appendixes I. Sample Assessment/Testing Tools II. Vaccine Products: Commonly Administered Pediatric Vaccines III. Chronic Care Management Worksheet IV. Care Plan Oversight Encounter Worksheet V. Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines VI. Effective Health Plan Appeals: The Ins and Outs VII. Sample Denial Tracking Tool Indexes Subject Index Code Index AAP/Bright Futures Recommendations for Preventive Pediatric Health Care (Periodicity Schedule)... Insert From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

10 ix Foreword The American Academy of Pediatrics (AAP) is pleased to publish this the 23rd 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 2018 Current Procedural Terminology (CPT ) codes and update of International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM) codes with guidelines for their application. New features are the addition of a chapter addressing telemedicine and new chapters separately addressing common surgical procedures and sedation and common testing and therapeutic services. Readers will also find several chapters reorganized and enhanced with more detail on appropriate coding and documentation. In addition the AAP is pleased to continue to offer Coding for Pediatrics 2018 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 2018 by accessing Coding for Pediatrics 2018 does not replace CPT ICD-10-CM or Healthcare Common Procedure Coding System; rather it supplements those manuals. Every effort has been made to include the 2018 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 as appropriate on the Coding for Pediatrics Web site ( 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 Review 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-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. 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 ( aap.org). Other resources include coding seminars presented at the AAP National Conference & Exhibition; webinars sponsored by the AAP ( instructional materials in AAP News including the Coding Corner; Pediatric ICD-10-CM: A Manual for Provider-Based Coding; and various quick reference cards. The use of these resources should provide the membership with the skills needed to report their services appropriately. The Division of Health Care Finance 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 at aapcodinghotline@aap.org. From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

11 x Acknowledgments Coding for Pediatrics 23rd 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. 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 COCN and the AAP Coding Publications Editorial Advisory Board. The members of these committees have each contributed extensive time in reviewing and updating content of the manual. We want to especially thank the following reviewers: Jamie Calabrese MD CPC FAAP David M. Kanter MD MBA CPC FAAP Steven E. Krug MD FAAP Jeffrey F. Linzer Sr MD FAAP Jeanne Marconi MD FAAP Linda Parsi MD MBA CPEDC CMOM CMC FAAP Renee F. Slade MD FAAP Sanjeev Y. Tuli MD FAAP I would like to particularly acknowledge those current and past COCN members who have devoted their time and expertise to providing a breadth of knowledge not otherwise possible: Lynn Wegner MD FAAP former COCN member and advocate for developmental and behavioral health issues; 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; David M. Kanter MD MBA CPC AAP alternate CPT advisor; Julia M. Pillsbury DO CPT Editorial Panel member; Jeffrey F. Linzer Sr MD AAP International Classification of Diseases 10th Revision Clinical Modification Editorial Advisory Board representative and ICD-11 Pediatrics Topic Advisory Group chairperson; and Richard A. Molteni MD COCN chair 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 James P. Scibilia MD 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; the Section on Telehealth Care specifically Peter Dehnel MD FAAP; and the Section on Neonatal-Perinatal Medicine coding trainers. This project would not have been completed were it not for the outstanding work of AAP staff. In the departments of Publishing and Membership Engagement Marketing and Sales Barrett Winston senior editor professional/clinical publishing; Jason Crase manager editorial services; Peg Mulcahy manager art direction and production; Leesa Levin-Doroba production manager practice management; and Mary Jo Reynolds marketing manager practice publications deserve special recognition for their outstanding skill and dedication to this project. In the Division of Health Care Finance I am especially appreciative of the support and professional expertise of Linda Walsh MAB division director and AAP staff support to the AAP COCN dedicated advocates for all of us who provide medical care to children. Edward A. Liechty MD Editor From Coding for Pediatrics rd Ed: Downloaded on Dec :04 AM at Published by AAP All rights reserved.

AMERICAN ACADEMY OF PEDIATRICS

AMERICAN ACADEMY OF PEDIATRICS The Role of the Primary Care Pediatrician in the Management of High-risk Newborn Infants ABSTRACT. Quality care for high-risk newborns can best be provided by coordinating