Billing Codes That Work

January 27th, 2011

Disclaimer: The codes included are to be used as a GUIDELINE and there is no guarantee of coverage but we hope this will help you get the help your child needs. This list is dynamic and will change as parents give us feedback on what worked and didn’t work for them. Please check back occasionally and send us any codes that worked successfully for you to help others. This is NOT meant to be legal or medical advice. Please note that merely having the proper codes doesn’t mean that your insurance company covers the treatment, but if they do, this will help.

Lab Tests Information and Tips

Traditional Therapies (ABA, Occupational, Physical and Speech Therapies)

 

Treatment CPT code ICD9 code Notes
Applied Behavioral Analysis, Cognitive Behavioral Therapy (ABA, CBT)
  96116   Neurobehavioral status exam (clinical assessment of thinking, reasoning and judgment, i.e., acquired knowledge, attention, language, memory, planning and problem solving, and visual spatial abilities), per hour of the psychologist’s or physician’s time, both face-to-face time with the patient and time interpreting test results and preparing the report.
  90804   Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 20 to 30 minutes face-to-face with the patient;
  90808   75-80 minutes of face to face behavior modifying therapy, outpatient
  97532   ABA Therapist/Instructor Code 97532 (billed in 15 minute units) Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes
  97532   Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact by the provider, each 15 minutes
  97535   Self-care/home management training (e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes
    742.9 Unspecified anomaly of brain, spinal cord, and nervous system
    315.9 Unspecified delay in developmentDevelopmental disorder NOS; Learning disorder NOS
    299.0 Autistic disorderChildhood autismInfantile psychosisKanner’s syndrome

Excludes:

disintegrative psychosis (299.1)

Heller’s syndrome (299.1)

schizophrenic syndrome of childhood (299.9)

    299.1 residual- a disability remaining from a disease or operation
    299.8 Other specified pervasive developmental disordersAsperger’s disorderAtypical childhood psychosis
    299.9 Unspecified pervasive developmental disorderChild psychosis NOSPervasive developmental disorder NOSSchizophrenia, childhood type NOS

Schizophrenic syndrome of childhood NOS

Occupational Therapy (OT)
  97003   Occupational therapy evaluation
  97004   OT Re-evaluation
  97110   Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  97112   Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
  97140   Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
  97530   Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
  97510   Group OT: Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
    783.42 gross motor delay
Swallowing problems 92526 787.20 787.20 Dysphagia, unspecified, V41.6; Treatment of swallowing dysfunction and/or oral function for feeding
Hypotonia   781.3 Lack of coordination (Ataxia NOS, Muscular incoordination)
    784.69 784.69 Other Symbolic Dysfunction (Acalculia; Agnosia; Agraphia NOS; Apraxia)
Speech Therapy (ST)
  92506   Evaluation of speech, language, voice, communication, and/or auditory processing
  92507   individual speech therapy
  92508   Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
  92508   Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals
  92597   Oral speech device evaluation
    315.32 Mixed receptive-expressive language disorder (Central auditory processing disorder)
    784.3 Aphasia (excluding dev. Aphasia)
    315.31 developmental aphasia
    315.39 Other Developmental Speech Disorder
    784.69 Other Symbolic Dysfunction (Acalculia; Agnosia; Agraphia NOS; Apraxia)
    315.39 OtherDevelopmental articulation disorderDyslalia, Phonological disorderExcludes: lisping and lalling (307.9); stammering and stuttering (307.0)
    784.6 Other symbolic dysfunctionExcludes:developmental learning delays (315.0-315.9)
    388.40 388.40 Abnormal auditory perception, unspecified
    338.42 92507 Speech/Language Therapy; 388.42 Hyperacute Hearing
    381.00 Chronic Otitis Media
Swallowing problems 92526 787.20 787.20 Dysphagia, unspecified, V41.6; 92526 Treatment of swallowing dysfunction and/or oral function for feeding
Auditory Integration Therapy/Training (AIT) 92510   Aural Rehabilitation
    388.43 Impairment of Auditory Discrimination
    388.40 Abnormal auditory perception, unspecified
    338.42 Hyperacute Hearing
    784.69 Other. (Acalculia, Agnosia, Agraphia NOS, Apraxia)
Physical Therapy (PT)
  97001   Physical therapy evaluation
  97002   Physical therapy re-evaluation
  97113   Therapeutic procedure, one or more areas, each 15 minutes; aquatic therapy with therapeutic exercises
  97116   Therapeutic procedure, one or more areas, each 15 minutes; gait training (includes stair climbing)
  97110   Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
  97530   Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
  97150   Therapeutic procedure(s), group (2 or more individuals)
  97112   Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Hypotonia   781.3 Lack of coordination (Ataxia NOS, Muscular incoordination)
    783.42 gross motor delay
Misc
Individual Skills 90809 H2014 Individual psychotherapy, insight oriented, behavior modifying and/or supportive, in an office or outpatient facility, approximately 75 to 80 minutes face-to-face with the patient; with medical evaluation and management services
Family Skills 90847 H2014 Family psychotherapy (conjoint psychotherapy) (with patient present)
Parent education 90887   Interpretation or explanation of results of psychiatric, other medical examinations and procedures, or other accumulated data to family or other responsible persons, or advising them how to assist patient
Nutritionist (Initial Visit) 97802   Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes. (this CPT code must only be used for the initial visit.) This code is to be used only once a year, for initial assessment of a new patient.
Nutritionist (ongoing treatment) 97803   All subsequent individual visits and intervention(s), face-to-face, each 15 minutes. This code is to be billed for all individual reassessments and all interventions after the initial visit (see 97802). This code should also be used when there is a change in the patient’s medical condition that affects the nutritional status of the patient.

Office Visits and Phone Consults

Treatment CPTcode  

ICD9 code Notes
Office Visit 99203 (new)   Detailed – low complexity (new patient)
  99214 (est.)   (established patient)
  99204 (new)   Detailed – moderate
  99214.21 (est.)    
  99205 (new)   Detailed – high complexity
  99215 (est.)    
  99354   for any additional time above this
Phone Consult- Physician 99441   5 to 10 minutes of medical discussion
  99442   11 to 20 minutes of medical discussion
  99443   21 to 30 minutes of medical discussion
      Use a combination of these to make an amount greater than 30 minutes.
Telephone ManagementNon-physician
  98966   5 to 10 minutes of medical discussion
  98967   11 to 20 minutes of medical discussion
  98968   21 to 30 minutes of medical discussion
Online E/M Service
  99444   Physician using the Internet or similar electronic communications network
  98969   Non-physician using the Internet or similar electronic communications network
  99366   Face-to-face with patient/family; participation by non-physician
  99367   Patient and/or family not present; participation by physician
  99368   Patient and/or family not present; participation by non-physician
Therapeutic/prophylactic/diagnostic IV Infusion/ Initial hour 90765    
Therapeutic/prophylactic/diagnostic IV Infusion/Additional hours 90766    
Phlebotomy Therapy 99195    
  90760 963.8 Note: NDC# TD DMPS, it’s 38779-0643-06 for the DMPS and 49452-3352-02 for the glutathione that it’s mixed with. 90760: Intravenous infusion, hydration; initial, 31 minutes to 1 hour
  90761 963.8 90761: Intravenous infusion, hydration; each additional hour (List separately in addition to code for primary procedure)

Here is some more information on Time-Based Coding.

Lab Tests

MONEY MONEY MONEY!

Not all doctors consider finances when making treatment decisions, but we parents live in the real world and may need to redirect the conversation to include finances.

Tell your doctor how much money you have to spend and ask him/her to prioritize tests and labs. Also, ask what the difference is between insurance-covered labs and specialty (non-insurance covered) labs. If the answer is convenience (because I like their test or all the stuff we need is on one neat report), consider asking them to order it through the insurance-covered lab, even if it’s not as convenient. Save your money for things that insurance won’t cover, don’t squander it when you don’t have to.

Note that there are 3 types of rates for tests: physician cost, insurance billed and cash prepay (parent). If your cost is $100 for cash prepay with a 70% reimbursement versus $300 insurance-billed with a 70% reimbursement, you are better off paying out of pocket and submitting to insurance for reimbursement.

  Cash Pre-Pay Insurance
Lab test cost $100 (70% reimbursement) $300 (70%)
Your out-of-pocket costafter reimbursement  

$30 $90

For tests your doctor recommends but your insurance company won’t cover, do a little investigating and call the labs to find out the parent pre-pay cost for each and compare them to what the doctor is wanting to charge you. If the doctor has a negotiated rate with the lab that’s much lower and then charges you a little (usually $15) for handling, you are better off going through the doctor.

Please note that not all doctors pass their savings on to their patients when they negotiate a special rate with the labs. As an informed consumer, call the labs before you do the tests and figure out which is the best way to go financially.

Please see Lab Tests and Codes (CPT)  for a large list of lab tests with their costs, CPT or ICD9 codes, and also the list of Common Co-Morbid Disorder Diagnosis Codes.

Lab Test Tips

Make sure you read test directions for tests BEFORE starting them (i.e., Do you have to be fasting? What medications might affect results? Do you have to stop certain supplements days prior? How are you going to ship the test?) This will ensure that you do not waste money by having to re-perform the test.

Some major labs (like Labcorp and Quest in the east) and hospitals will pull blood and do the special work required (spinning, freezing, separating whole cells, etc) and ship them to the specialty labs for you as long as you pay for the blood draw and give them the COMPLETE kit with instructions and pre-paid shipping bag.

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