Pediatric Coding Alert

Don't let frequent denials stop you from coding a vision acuity screening test (99173) with a preventive medicine service. Correct coding requires you to report the screening, but you may need some added ammunition to show insurers that they should cover the service.

Faced with numerous denials for CPT 99173 (Screening test of visual acuity, quantitative, bilateral), 99382-99383 and 99392-99393 (Preventive medicine services), many pediatric coders question if they should separately report a vision screening. "Am I misunderstanding the definition of 99173 when it is performed with a well-child exam?" asks Carmen Nino, office manager for pediatrician Takashi Yoshida, MD, in Sunnyvale, Calif. Payers keep denying 99173 as a nonpayable code stating that they consider it a component of the other billed E/M code.

Because the American Academy of Pediatrics (AAP) recommends that all preschool children be screened for visual acuity and strabismus by age 4 as a part of regular preventive care, most pediatricians perform 99173 with early (99382, 99392) or late childhood (99383, 99393) preventive medicine services. "Early detection and prompt treatment of ocular disorders in children is important to avoid lifelong permanent visual impairment," the AAP states.

CPT permits billing a vision screening provided with a preventive medicine service, says Elizabeth B. Lange, MD, a pediatrician with Waterman Pediatrics in Providence, R.I. "Other identifiable services unrelated to this screening test provided at the same time may be reported separately (e.g., preventive medicine services)," states CPT in the parenthetical notes following 99173. CPT's introductory preventive medicine service notes reinforce, "Immunizations and ancillary studies including laboratory, radiology, other procedures or screening tests identified with a specific CPT code are reported separately." Regardless of these directives, many managed-care organizations (MCOs) bundle the screening test with well-child healthcare, Lange says.

Do not allow lack of coverage to deter you from reporting 99173. "Whether the insurer reimburses for this code or not, each practitioner should accurately code for all services provided to a patient on any given day," Lange says.

Some Medicaid programs reinforce coding 99173 regardless of coverage. For instance, North Carolina Medicaid guidelines indicate that you should list vision screening CPT codes in addition to the preventive medicine CPT code. Despite this directive, the carrier allows no additional reimbursement for 99173.

Always billing the screening test will also ensure that you do not sacrifice any reimbursement. Rhode Island's main two insurers, Blue Cross Blue Shield of Rhode Island (BCBSRI) and United Healthcare, kept denying 99173, so Lange's billers stopped reporting the service. "Because some of the smaller companies, such as Cigna and Tufts, were paying for the code, I missed out on some private insurance money," she says.

Consistent reporting will give you concrete data to show insurers that pediatrician-provided screenings cost less than ophthalmologist-performed services. "I called BCBSRI and threatened to refer all vision screenings to ophthalmologists and pointed out the added expense this would create for the insurer," Lange says. But because she had no records to show how often she was performing the service, she could not substantiate how much her services saved the company.

Before you blame noncoverage on the insurer, make sure you link the vision test to a different diagnosis than the preventive medicine service. CPT does not require separate diagnoses to reimburse a same-day E/M and other service. Using different ICD-9 codes, however, will help show the payer that the pediatrician performed two separate services.

Therefore, you should link V72.0 (Examination of eyes and vision) to 99173, and link V20.2 (Routine infant or child health check) to 99382-99383 and 99392-99393, says Cathy Fata, office manager for Riverdale Pediatrics P.C. in New York. "Do not use V20.2 for both the vision screening and the well exam," she says.

3. Try Using Modifier -25

You may need to append modifier -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the appropriate preventive medicine service code. CPT does not require a modifier on the E/M code to show that the screening is a significant, separately identifiable service from the well check. Some insurers, however, set up their software systems to look for modifier -25 on claims containing a same-day E/M service and other procedure. Without the modifier, the edit may automatically reject the screening. So, if an insurer denies the screening test, try appending modifier -25 to the E/M code (99382-99383 and 99392-99393), Fata says.
 
Although appending the modifier may help your claim get paid, some experts discourage using it with the vision screening. Because 99173 is a relatively new code the AMA added it to CPT 2000 many insurers are reluctant to pay for the screening, which was previously included in the preventive medicine service. Therefore, experts advocate trying to get reimbursement without using the modifier. "Since modifier -25 is not technically correct in this situation, play by CPT's rules and make the insurance companies do the same," says Chip Hart, marketer for the Winooski, Va.-based Physician's Computer Company, which supports and develops pediatric-specific software.
 
If payers reject 99173, consider trying modifier -25 as an option. But, if payers do not require it, don't use it.

4. Don't Accept 'Medicare Bundles the Service'

Also watch out for MCOs that blame the 99173 bundle on Medicare. Although pediatricians rarely have Medicare patients, numerous insurers claim that they follow Medicare's policies. But CMS does not designate 99173 as a bundled service, Hart says. "Therefore, this excuse is a bit disingenuous on the part of the commercial insurance company."

Explain to the payer that Medicare does not bundle the screening. The National Physician Fee Schedule instead identifies the screening test as a noncovered service Medicare deems all preventive service noncovered and thus not payable.

In contrast, Medicare "pays" for bundled services by including payment in the procedure that the bundled service is incident-to.

Although fighting payers' denials may seem daunting, persistence pays off. Insurers figure that if they make reimbursement difficult for a service, such as 99173, most pediatric practices will simply stop billing for it, Hart warns. "But, you'll never get paid if you don't bill."

Rather than taking on each claim individually, he recommends gathering a month's worth of denials and presenting them to the insurance representative. "Then, start the appeals process."
 
Lange concurs with this strategy. "Practices who now get 99173 covered flooded claims offices with appeals until they wore them down."

In your battle to get payment for 99173, you should include supplementary documentation that supports the screening as a separate, nonbundled service. With each appeal, submit a copy of:

1. CPT's 99173 instructions

2. CPT's introductory preventive medicine service notes

3. Medicare's fee schedule that identifies 99173 as status "N," a noncovered service.