Download Pediatric Office Superbill 2015 - AAP Pediatric Coding Newsletter

Pediatric Office Superbill 2015
NEW
OFFICE VISITS
EST
IMMUNIZATIONS
Clinical staff—5 min
99211
90700
DTaP, <7 y, IM
92551
Screening test pure tone, air only
J7611
Albuterol, inhal, concentrated, 1 mg
99201
Office/OP—10 min
99212
90723
DTaP-Hep B-IPV
92552
Pure tone audiometry, air only
J7612
Levalbuterol, inhal, concentrated
Office/OP—15 min
99213
90698
DTaP-Hib-IPV
92567
Tympanometry
J7613
Albuterol, inhal, unit, 1 mg
99202
Office/OP—20 min
90696
DTaP-IPV
92583
Select picture audiometry
J7614
Levalbuterol, inhal, unit, 0.5 mg
90655
Flu, no preserv, trivalent, 6–35 mo
94010
Spirometry
J7506
Prednisone, oral, per 5 mg
90656
Flu, no preserv, trivalent, >3 y
94060
Spirometry, pre/post-bronchodilator
J7510
Prednisolone, oral, per 5 mg
90657
Flu, trivalent, 6–35 mo
94640
Nebulizer
J8540
Dexamethasone, oral, 0.25 mg #________
Office/OP—25 min
99203
99214
Office/OP—30 min
Office/OP—40 min
99215
OTHER PROCEDURES
OTHER MEDICATIONS
99204
Office/OP—45 min
90658
Flu, trivalent, >3 y
94664
Demonstrate/teach inhal meds
Other
99205
Office/OP—60 min
90685
Flu, no preserv, quadrivalent, 6–35 mo
94760
Noninvasive ear/pulse oximetry single
DIAGNOSIS
NEW
PREVENTIVE MEDICINE EST
90686
Flu, no preserv, quadrivalent, >3 y
96110
Developmental screen #________________
R10.84
Abdominal pain, generalized
R10.3-
Abdominal pain, lower: 0 unspec; 1 RLQ;
2 LLQ; 3 periumbilical
R10.1-
Abdominal pain, upper: 0 unspec;
1 RUQ; 2 LUQ; 3 epigastric
H93.29-
Abnormal auditory perceptions: 1 rt;
2 lt; 3 bilat
99381
<1 y
99391
90687
Flu, quadrivalent, 6–35 mo
96127
Emotional/behavioral assessment #____
99382
1–4 y
99392
90688
Flu, quadrivalent, >3 y
96360
IV infusion hydration—initial 31 min–1 hour
99383
5–11 y
99393
90672
Flu, quadrivalent, intranasal
+96361
IV infusion hydration—each addl hour
99384
12–17 y
99394
90633
Hep A, 2 dose
99173
Vision screen, acuity
99385
18–39 y
99395
90743
Hep B, adol, 2 dose, IM
99174
Instrument-based occular screen
Application topical fluoride varnish
90744
Hep B, ped/adol, 3 dose, IM
99188
R73.09
Abnormal glucose level
99401
15 min
90748
Hep B-Hib, IM
Other
R25.0
Abnormal head movements
99402
30 min
90647
Hib, PRP-OMP
INJECTIONS
P09
Abnormal neonatal screen
Allergy injection, 1
R76.11
Abnormal TB test results
Abrasion, site ___________________________
PREVENTIVE MEDICINE COUNSELING
99403
45 min
90648
Hib, PRP-T
95115
99404
60 min
90649
HPV, quadrivalent
95117
Allergy injections, >1
By site*
99406
Smoking cessation—3–10 min
90650
HPV, bivalent
96372
Therapeutic prophylactic/dx inj SC/IM
L02.-
99407
Smoking cessation—>10 min
90713
IPV
LABORATORY
Abscess, cutaneous /carbuncle/furuncle
site______________________________________
________ infectious _______noninfectious
99408
Audit/DAST w/SBI—15–30 min
90733
Meningococcal, polysac, SC
81000
Urinalysis nonauto w/ scope
L70.-
99409
Audit/DAST w/SBI—>30 min
90734
Meningococcal conj, tetravalent, IM
81002
Urinalysis nonauto w/o scope
Acne: 0 vulgaris; 1 conglobata; 2 varioliformis; 4 infantile; 8 other; 9 unspec
90707
MMR
82272
ADD
MMRV
Blood occult peroxidase actv qual feces,
1–3 spec
F90.0
90710
F90.1
ADHD
N89.5
Adhesions, vaginal
F43.20
Adjustment disorder, unspec
F10.10
Alcohol abuse, uncomplicated
F10.20
Alcohol dependence, ­uncomplicated
J30.-
Allergic rhinitis d/t: 1 pollen (hay fever);
2 other (seasonal); 5 food; 9 unspec
J30.8-
Allergic rhinitis d/t: 1 animal (cat/dog);
9 other
N91.-
Amenorrhea: 0 primary; 1 secondary;
2 unspec
OFFICE/OUTPATIENT CONSULTATIONS
99241
Office consultation—15 min
99242
Office consultation—30 min
90670
Pneumococcal, 13 valent
99243
Office consultation—40 min
90732
Pneumococcal polysac, 23 valent
99244
Office consultation—60 min
90680
Rotovirus, 3 dose, oral
99245
Office consultation—80 min
90681
Rotavirus, 2 dose, oral
90715
Tdap, ≥7 y
Varicella (chickenpox)
HOURLY CRITICAL CARE
99291
Critical care—1st hour
90716
+99292
Critical care—addl 30 min
Other
PROLONGED SERVICES
SURGICAL PROCEDURES
+99354
Office/OP dir contact—1st hour
10060
Incision & drainage, abscess
+99355
Office/OP dir contact—30 min #_________
10120
Incision & removal FB skin, simple
82948
Glucose blood reagent strip
82962
Glucose blood
85018
Blood count hemoglobin
86308
Heterophile antibodies screen
86580
Skin test, tuberculosis, ­intradermal
87070
Culture, other specimen, aerobic
87086
Urine culture/colony count
87430
Strep A, enzyme immunoassay
87804
Influenza, rapid A____ B___
87880
Strep A, rapid
D50.9
Anemia, iron deficiency, unspec
36405
Venipuncture, <3 y, phys/qhp skill,
scalp vein
R63.0
Anorexia (loss of appetite)
F41.1
Anxiety disorder, generalized
F41.9
Anxiety disorder, unspec
99358
Before/after dir care—1st hour
120__
Simple repair loc __________ size ________
+99359
Before/after dir care—30 min #_________
16000
Initial treatment of burn(s), local
16020
Dress/debrid p-thick burn(s), small
(<5% TBSA)
36410
Venipuncture, ≥3 y, phys/qhp skill
Q23.0
Aortic valve stenosis, ­congenital
17110
Destruct benign lesion 1–14
36415
Collection venous blood venipuncture
P28.-
Apnea, NB: 3 sleep; 4 other (­prematurity)
17111
Destruct benign lesion ≥15
36416
Collection capillary blood specimen
R06.81
Apnea, child
17250
Chemical cautery tissue
99000
Specimen handling, office-lab
G47.30
Apnea, sleep, unspec
24640
Treat elbow dislocation (nursemaid
elbow)
J45.991
Asthma, cough variant
28190
Removal FB foot, SC
J45.2J45.3J45.4J45.5-
Asthma, mild intermittent:
Asthma, mild persistent:
Asthma, moderate persistent:
Asthma, severe, persistent:
0 uncomplicated; 1 w/ (acute) exacerbation; 2 w/ status asthmaticus
ADD-ON SERVICES
99050
Medical services after hours
99051
Medical services eve/wkend/holiday
99058
Office emergency care
99060
Out of office emerg medical service
IMMUNIZATION ADMINISTRATION
90460
IA <19 y any rte 1st/only comp #_________
+90461
IA <19 y any rte addl comp #____________
30300
Removal FB intranasal
90471
IA 1st vaccine IM/SC
30901
Control nosebleed
+90472
IA each addl vaccine IM/SC #___________
90473
IA intransl/oral 1st vaccine
+90474
IA intransl/oral each addl vaccine #_____
51701
65205
69200
69210
Insert bladder catheter
Removal FB from eye
Removal FB external auditory canal
Removal impacted earwax, ______ bilat
36406
Venipuncture, <3 y, phys/qhp skill,
other vein
Other
INJECTED MEDICATIONS
J1200
Benadryl up to 50 mg
J0558
Bicillin C/R 100,000 units #_____________
J0561
Bicillin L-A 100,000 units #______________
J1100
Decadron 1 mg #________________________
Q21.1
Atrial septal defect, congenital
J0171
Epinephrine 0.1 mg
Q21.2
Atrioventricular septal defect
J2550
Phenergan up to 50 mg
F84.0
Autism
J0696
Rocephin per 250 mg #__________________
R78.81
Bacteremia
Z68.51
Z68.52
Z68.53
Z68.54
BMI, pediatric, <5th percentile for age
5th–<85th percentile for age
85th–<95th percentile for age
≥95th percentile for age
+ indicates an add-on code; - indicates that additional characters are required for the complete ICD-10-CM code.
90378
RSV IM use,
*indicates that a seventh character is required to define episode of care—7th Character for Encounter: ______________
A — initial encounter; D — subsequent encounter (used for clsd fx w/ routine healing) ; G — subsequent encounter for clsd fx w/ delayed healing; S — sequela
Note: Some common brand names are listed for informational purposes only. Inclusion does not imply endorsement. The American Academy of Pediatrics does not recommend any specific brand.
per 50 mg (Synagis) #______
Q90.9
Down syndrome, unspec
H00.01-
Hordeolum externum site ______________
J15.9
Pneumonia, bacterial, unspec
P83.4
Breast engorgement, NB
N94.4
Dysmenorrhea, primary
P83.5
Hydrocele, congenital
J18.9
Pneumonia, unspec organism
J21.9
Bronchiolitis, acute, unk organism
R30.0
Dysuria
N43.3
Hydrocele, unspec
J12.9
Pneumonia, viral, unspec
J21.0
Bronchiolitis, acute, d/t RSV
L20.83
Eczema, infantile, acute/chronic
J35.2
Hypertrophy, adenoids
P07.2-
Premature, <28 wk______________________
J98.01
Bronchospasm, acute
L20.84
Eczema, intrinsic, allergic
N62
Hypertrophy, breast
P07.3-
Premature, 28–37 wk ____________________
J45.990
Bronchospasm, exercise induced
R60.0
Edema, localized
J35.1
Hypertrophy, tonsils
R21
Rash
By site*
Burn degree _____________ /site _________
R03.0
Elevated BP reading, w/o hypertension
R06.4
Hyperventilation
J31.0
Rhinitis, chronic
B37.2
Candidiasis of skin/nail
E78.0
Elevated cholesterol
H61.2-
Impacted cerumen: 1 rt; 2 lt; 3 bilat
B08.20
Roseola infantum
B37.3
Candidiasis of vulva/vagina
R15.9
Encoporesis
L01.00
Impetigo
M41.1-
I49.9
Cardiac arrhythmia, unspec
B27.90
Infectious mono, unspec
Scoliosis, idiopathic,
site___________________
By site
Cellulitis site____________________________
G80.-
Cerebral palsy, spastic: 0 quadriplegic,
congenital; 1 diplegic; 2 hemiplegic
J09.XJ10.-
Influenza, d/t novel A
Influenza, d/t other
identified
Influenza, unidentified
G80.-
Cerebral palsy: 3 athetoid/­dystonic;
4 ataxic; 8 other; 9 unspec
M54.2
Cervicalgia
Z02.82
Z02.4
Z09
Z23
Z76.81
Z02.0
Z02.5
Z48.02
Encounter for
Adoption exam
Drivers license
Follow-up (resolved condition)
Immunizations
Pre-birth/adoption
School physical
Sports physical
Suture removal
R07.9
Chest pain, unspec
N39.44
Enuresis, nocturnal
T74.-*
Child abuse, confirmed: 12 physical;
22 sexual; 32 psychological
R32
Enuresis, other
Z04.-
Child abuse, ruled out: 72 physical;
42 sexual
P78.83
Esophageal reflux, NB
Child abuse, suspected: 12 physical;
22 sexual; 32 psychological
R62.51
Failure to thrive, child
P92.6
Failure to thrive, NB
Child neglect, confirmed
R53.83
Fatigue/lack of energy
Child neglect, suspected
T16.-*
FB ear: 1 rt; 2 lt
J00
Cold/nasopharyngitis/rhinitis, acute
T15.1-*
R10.83
Colic (infantile)
F91.-
Conduct disorder: 1 childhood-onset;
2 adolescent-onset; 9 unspec
H10.1-
Conjunctivitis, acute, atopic: 1 rt;
2 lt; 3 bilat
DIAGNOSIS, CONTINUED
T76.-*
T74.02-*
T76.02-*
H10.3K59.00
L23.-
Conjunctivitis, acute, unspec: 1 rt; 2 lt;
3 bilat
Constipation, unspec
Contact derm, allergic d/t______________
w/ pneumonia
w/ resp sx
w/ GI sx
w/­other sx
Screening for:
Cardiovascular disorders
Developmental disorders
Diabetes Mellitus
Lipid disorders
Nutritional disorders
Genetic disorders
TB
Traumatic Brain Injury
Adolescent
Juvenile
By site*
Insect bite site__________________________
_______infectious _______noninfectious
Z79.4
Insulin use (report w/ DM codes)
Z13.6
Z13.4
Z13.1
Z13.220
Z13.21
Z13.79
Z11.1
Z13.850
P59.9
Jaundice, NB, unspec
L21.9
Seborrheic dermatitis, unspec
R17
Jaundice, unspec
R56.00
Seizure, febrile, simple
M40.20-
Kyphosis, unspec, site___________________
G40.-
Seizures/­epilepsy
J04.0
Laryngitis, acute
B85.-
Lice: 0 head; 1 body
Lymphadenitis, acute—face/head/neck
lower limb
other sites
trunk
upper limb/axilla
J01.90
Sinusitis, acute, unspec
J01.91
Sinusitis, acute, recurrent, unspec
H04.55-
FB eye, conjunctiva: 1 rt; 2 lt
L04.0
L04.3
L04.8
L04.1
L04.2
Stenosis, acquired nasolacrimal duct:
1 rt; 2 lt; 3 bilat
T15.0-*
FB eye, corneal: 1 rt; 2 lt
G43.-
Migraine
Q10.5
Stenosis, congenital of lacrimal duct
T17.1*
FB, nose
J02.0
Strep pharyngitis/strep sore throat
F43.0
Stress reaction, acute
L55.-
Sunburn: 0 1st degree; 1 2nd degree
H60.33-
Swimmer’s ear: 1 rt; 2 lt; 3 bilat
K00.7
Teething syndrome
Molluscum contagiosum
Q21.3
Tetralogy of Fallot
Murmur, heart, benign/­innocent/func
B37.0
Thrush, oral
Tinea corporis/body ringworm
R04.0
By site*
By site*
R63.3
P92.5
P92.8
P92.2
Epistaxis
J11.-
FB other, site ____________________________
FB, superficial, site ______________________
G43.8-
Migraine, menstrual
Feeding problems
Feeding problems, NB, breastfeeding
Feeding problems, NB, other
Feeding problems, NB, slow feeding
B08.1
R01.0
w/ aura
w/o aura
w/ status
w/o status
w/ aura
w/o aura
w/ status
w/o status
Intractable
w/ status
epilepticus
L25.-
Contact derm d/t _______________________
R50.9
Fever, NOS
R01.1
Murmur, heart, unspec
B35.4
By site*
Contusion, site___________________________
R50.83
Fever, postvaccination
M79.1
Myalgia
B35.6
Tinea cruris/groin ringworm
Fever w/ other condition
R11.0
Nausea
B35.3
Tinea pedis/athlete’s foot
B35.1
Tinea unguium/dermatophytosis nail
J03.90
J03.91
J03.00
J03.01
Tonsillitis
Acute
Acute, recurrent
Strep, acute
Strep, acute, recurrent
M43.6
Torticollis
R63.6
Underweight (add BMI)
J06.9
URI
N39.0
UTI
R05
Z71.41
Z30.09
Z71.3
Z71.89
Z71.6
L21.0
Cough
R50.81
Counseling for
Alcohol abuse
Contraception
Dietary (add BMI)
Other (exercise, vaccine)
Tobacco
B08.3
Fifth disease
S53.03-* Nursemaid’s elbow: 1 rt; 2 lt
R68.12
Fussy infant
E66.09
Obesity d/t excess calories (add BMI)
By site*
Fx, closed, site__________________________
E66.8
Obesity, other (add BMI)
K29.70
Gastritis, unspec
Z04.1
Obs suspect cond, r/o, car accident
Cradle cap/seborrhea capitis
A09
Gastroenteritis/colitis, infectious
Z04.8
Obs suspect cond, r/o, other
Obs suspect cond, r/o, other accident
OM, acute, nonsupparative: 1 rt; 2 lt;
3 bilat; 4 rec rt; 5 rec lt; 6 rec bilat
J05.0
Croup
K52.9
Gastroenteritis, noninf, unspec
Z04.3
E84.-
Cystic fibrosis, w/: 0 pulmonary
manifest; 8 other manifest; 9 unspec;
19 other intestinal manifest
A08.4
Gastroenteritis, viral (AGE)
H65.19-
K21.9
GERD, w/o esophagitis
L92.9
Granuloma, skin (umbilical)
B08.4
Hand, foot and mouth
R51
Headache
Z01.110
Hearing exam following failed screen
Z01.118
Hearing exam w/ other abn findings
Z01.10
Hearing exam w/o abn findings
H65.41-
Developmental disorder of speech/
language
H90.5
Hearing loss, sensorineural unspec
R31.1
L22
Diaper rash/dermatitis
R19.7
E08.9
E86.0
R62.0
R62.50
K02.9
F32.F80.9
E10.9
E11.9
H65.0-
OM, acute, serous: 1 rt; 2 lt; 3 ­bilat;
4 rec rt; 5 rec lt; 6 rec bilat
Z23
Vaccines administered
H66.00-
OM, acute, suppurative: 1 rt; 2 lt;
3 bilat; 4 rec rt; 5 rec lt; 6 rec bilat
B01.9
Varicella, uncomplicated
OM, acute, suppurative, w/ rup eardrum:
1 rt; 2 lt; 3 bilat; 4 rec rt; 5 rec lt;
6 rec bilat
Q21.0
Ventricular septal defect
B09
Viral exanthema
B34.9
Viral syndrome
OM, chronic, allergic: 1 rt; 2 lt; 3 bilat
R11.10
Vomiting, unspec
H65.3-
OM, chronic, mucoid: 1 rt; 2 lt; 3 bilat
R11.11
Vomiting w/o nausea
Hematuria benign essential micro
H65.2-
OM, chronic, serous: 1 rt; 2 lt; 3 bilat
B07.0
Warts, plantar/verruca plantaris
R31.0
Hematuria, gross
P38.9
Omphalitis w/o hemorrhage
Diarrhea
B07.8
Warts, viral (common/flat)
K40.-
Hernia, inguinal: 20 bilat; 90 unilat
DM d/t underlying condition w/o
complications
Weight gain, abnormal
Hernia, umb, w/o obstruct or gangrene
Open wound, site_______ Puncture
_________________________ Laceration
Bite
w/ FB
R63.5
K42.9
By site
and
injury*
R63.4
Weight loss, abnormal
Z00.129
Well-baby/child exam
H92.0-
Otalgia: 1 rt; 2 lt; 3 bilat
Z00.121
Well-baby/child exam w/ abn findings
H60.50-
Otitis externa, unspec­: 1 rt; 2 lt; 3 bilat
Z00.110
Well-NB exam, <8 d
E66.3
Overweight (add BMI)
Z00.111
Well-NB exam, 8–28 d
R52
Pain, generalized
R06.2
Wheezing
M79.6-
Pain, limb, site___________________________
J02.9
Pharyngitis, acute
J31.2
Pharyngitis, chronic
Dehydration
Delayed milestones (­ childhood)
Delayed physiologic ­development
Dental caries, unspec
Depressive disorder, major, single epi:
0 mild; 1 moderate; 9 unspec
DM, type 1, w/o complications
DM, type 2 w/o complications
H66.01-
History of _______________________________
History (family) of _______________________
+ indicates an add-on code; - indicates that additional characters are required.
*indicates that a seventh character is required to define episode of care—7th Character for Encounter: ______________
A — initial encounter; D — subsequent encounter (used for clsd fx w/ routine healing) ; G — subsequent encounter for clsd fx w/ delayed healing; S — sequela
While every effort has been made to ensure the accuracy of this superbill, the American Academy of Pediatrics does not guarantee that this superbill is
accurate, complete, or without error. The recommendations herein 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.
Current Procedural Terminology (CPT®) 5-digit codes, nomenclature, and other data are copyright © 2014 American Medical Association. All Rights Reserved.
Copyright © 2015 American Academy of Pediatrics. All Rights Reserved. The American Academy of Pediatrics does not review or endorse any modifications
made to this document and in no event shall the AAP be liable for any such changes.