Coding for Pediatrics 2018.

547 Pages·2018·6.756 MB·English

Coding for
Pediatrics 2018

A MANUAL FOR PEDIATRIC DOCUMENTATION AND PAYMENT
23rd Edition • For Use With AMA CPT® 2018
The indispensable how-to guide on pediatric
coding. Covers CPT and ICD-10-CM with
expert advice, tips, and guidelines.
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Coding for
Pediatrics 2018
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A Manual for Pediatric Documentation
and Payment
For Use With AMA CPT® 2018
23rd 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
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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 60007-1019
Telephone: [phone]
Facsimile: 847/434-8000
www.aap.org
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 60007-1019
© 2018 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
http://ebooks.aappublications.org and click on © Get Permissions; you may also fax the permissions editor at 847/434-8780 or
e-mail [e-mail]).
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.
11-35M 1 2 3 4 5 6 7 8 9 10
MA0832
ISBN: 978-1-61002-102-9
eBook: 978-1-61002-108-1
ISSN: 1537-324X
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2017–2018
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
2017–2018
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
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Disclaimer
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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 (www.aap.org/cfp) routinely
to find any corrections due to errata in the published version.
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Copyright Acknowledgment
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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.
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In Memoriam
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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 remem-
ber 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.
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Contents
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Foreword .................................................................................................................................................... ix
Acknowledgments ......................................................................................................................................... x
Chapter 1
New and Revised CPT® Codes for 2018 .........................................................................................................1
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 ....................................................................................................................................131
Chapter 6
Preventive Services ....................................................................................................................................145
Chapter 7
Evaluation and Management Services in the Office, Outpatient, Home, or Nursing Facility Setting ..........175
Chapter 8
Managing Chronic and Complex Conditions .............................................................................................213
Chapter 9
Pre-birth Counseling and Care of the Newborn .........................................................................................241
Chapter 10
Noncritical Hospital Evaluation and Management Services ........................................................................261
Chapter 11
Emergency Department Services ...............................................................................................................289
Chapter 12
Critical and Intensive Care ........................................................................................................................315
Chapter 13
Telemedicine ..............................................................................................................................................339
Chapter 14
Allied Health and Clinical Staff Services ...................................................................................................349
Chapter 15
Common Surgical Procedures and Sedation ...............................................................................................375
Chapter 16
Common Testing and Therapeutic Services ................................................................................................407
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Chapter 17
Coding to Demonstrate Quality and Value .................................................................................................433
Chapter 18
Preventing Fraud and Abuse: Compliance, Audits, and Paybacks ................................................................449
Chapter 19
The Business of Medicine: Working With Current and Emerging Payment Systems .................................467
Chapter 20
Continuing Education Units (CEUs) for American Academy of Professional Coders .................................485
Appendixes ................................................................................................................................................493
I. Sample Assessment/Testing Tools ...........................................................................................................495
II. Vaccine Products: Commonly Administered Pediatric Vaccines .............................................................496
III. Chronic Care Management Worksheet .................................................................................................499
IV. Care Plan Oversight Encounter Worksheet ...........................................................................................500
V. Global Per Diem Critical Care Codes: Direct Supervision and Reporting Guidelines ............................501
VI. Effective Health Plan Appeals: The Ins and Outs .................................................................................504
VII. Sample Denial Tracking Tool ...............................................................................................................508
Indexes
Subject Index .............................................................................................................................................509
Code Index ................................................................................................................................................523
AAP/Bright Futures “Recommendations for Preventive Pediatric Health Care”
(Periodicity Schedule) ............................................................................................................................Insert
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Foreword
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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 sub-
specialists, 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 sup-
port a ppropriate 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 con-
tinue 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 www.aap.org/cfp. 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 (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 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 (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, includ-
ing 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 p roblem
areas not adequately covered in this manual. The AAP Coding Hotline can be accessed through e-mail at
[e-mail].