Pediatric Coding Alert

An ounce of prevention and the right diagnosis can spell victory when you report a well visit and screening.

Pediatricians and pediatric coders cite billing for a preventive medicine exam with add-on services, such as hearing screenings, as one of their top coding dilemmas. Increased payer scrutiny and frequent denials for one or both services can muffle the most experienced coder's strength and zap your practice's bottom-line. But perseverance coupled with coding and diagnosis guidelines will win the fight.

Coding conventions are on your side in this battle. CPT specifically states that preventive medicine services do not include screenings, says Catherine A. Hudson, RMA, RPT, registered medical assistant and phlebotomy technician for Cumberland Pediatrics PC in Marietta, Ga. "Immunizations and ancillary studies including laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately," according to CPT's preventive medicine services notes. Therefore, when a pediatrician performs a hearing screening during a preventive medicine service, you should report the visit and test separately.

For example, a mother brings in her 5-year-old son, an established patient, for an annual preventive examination. The pediatrician also conducts a hearing screening. You should report preventive medicine code 99393 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; late childhood [age 5 through 11 years]) based on the child's age and status. In addition, you should assign CPT 92551 (Screening test, pure tone, air only) for the screening test.

Despite CPT's clear directions, you may think payers will not cover the screening separately. Claims-processing experience may have led you to this erroneous conclusion.

But if you provide the correct diagnoses for the preventive medicine service and the hearing test, you should receive payment. "Most insurance will pay for the screening," Hudson says. "We will occasionally run across a company that won't."

To improve reimbursement, you should report a different diagnosis for each service, says Victoria Jackson, administrator and chief executive officer of Southern Orange County Pediatric Associates and owner and executive director of OMNI Management Inc., a medical practice management and billing company in southern California. Consequently, in the above example, you should link V20.2 (Routine infant or child health check) to the preventive medicine code (99393) and V72.1 (Special investigations and examinations; examination of ears and hearing) to the screening (92551). "Different diagnoses may help the payer understand that the pediatrician performed two separate services," she says.

If commercial carriers still deny payment for the screening, send them a copy of CPT's introductory preventive medicine services notes.

You may need to append the preventive medicine service with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Although CPT does not require a modifier on the E/M code, if an insurer denies the service, try using modifier -25, says Charles A. Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in Medford, N.J.