July 20, 2017
Using the correct age-banded procedure code is essential to accurate and timely claims payment. In both the Current Procedural Terminology (CPT®) code set and the Healthcare Common Procedure Coding System (HCPCS), many codes have specific age ranges. Incorrect usage of these age-banded procedure codes will result in an edit (“Procedure Code not Typical for Patient Age”) and a payment denial.
Finding the correct age-banded codes can be a challenge. To correctly submit age-banded procedure codes and avoid a claim denial, it helps to understand professional coding guidelines on age-banded procedures.
In both the CPT and HCPCS code sets, age-range guidelines are explained either directly in the CPT codebook's coding guidelines or as part of the code description for both CPT and HCPCS codes. These age ranges need to be carefully matched to the patient's age at the time of care.
The following examples explain best coding practices with age-banded codes:
Preventive Medicine Services: CPT Codes 99381 - 99397
These codes are broken out between new and established patient visits and by the age of the patient. The age of the patient at the time of the visit should match the age band of the preventive medicine visit code.
- 99381- Initial comprehensive preventive medicine evaluation and management of an individual including an age and general appropriate history, exam, counseling/guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
- 99382 - early childhood (age 1-4 years)
- 99384 - adolescent (age 12-17 years)
- 99386 - adult 40-64 years
- 99393 - established patient; late childhood (age 5-11 years)
- 99395 - adult 18-39 years
- 99397 - adult 65 years and older
Vaccine administration: CPT Codes 90460 - 90474
The CPT codebook identifies guidelines that differentiate vaccination administration codes for patients through age 18 years and a different set of administration codes for patients over 18 years of age. It's critical to use the correct administration code for the age of the patient at the time of the service:
Vaccine administration for patients through age 18 years:
- 90460 - Immunization administration through 18 years of age
- +90461 - each additional vaccine or toxoid component
Vaccine administration for patient over 18 years of age:
- 90471 - Immunization administration, percutaneous, intradermal, subcutaneous or intramuscular; one vaccine
- +90471 - each additional vaccine
- 90473 - Immunization administration by intranasal or oral route; one vaccine
- +90474 - each additional vaccine
Cast Supplies and Casting: HCPCS Codes Q4001 - Q4048
This large range of HCPCS codes are age-banded and differentiated by anatomic location of the cast and cast materials used. The age bands are either pediatric (0-10 years) or adult (11 years+). Careful selection of the correct cast for the age of the patient at the time of the casting will help avoid a denial of reimbursement.
- Q4005 - Cast supplies, long arm cast, adult (11 years+), plaster
- Q4032 - Cast supplies, long leg case, pediatric (0-10 years), fiberglass
- Q4033 - Cast supplies, long leg cylinder cast, adult (11 years+), plaster
- Q4044 - Cast supplies, long leg splint, pediatric (0-10 years), fiberglass
We'll continue to edit for these age-to-procedure conflicts. To avoid future line or claim denials, review the official coding guidelines and information in your coding applications or the 2017 CPT Professional Codebook or the HCPCS Level II Codebook.