Pediatric Coding Alert

Not billing CPT 99211 for PPD readings? You could be losing $21 per visit

If you're questioning whether to bill a nurse visit when you interpret a tuberculosis test result, you're not alone. Faced with numerous endorsements that you can report a nurse visit for interpreting PPD test results, pediatricians who question this billing method's legitimacy may lose $22 per visit for no good reason. (Fees are based on unadjusted Medicare National Physician Fee Schedule for 99211: 0.57 relative value units x $37.34 conversion factor = $21.28.)

Wary MDs: Normally, physicians are the first to fight for every earned penny. Therefore, to hear them argue otherwise is an interesting development. "But physicians' reservations about reporting a 99211 for a TB interpretation are twofold," says Kent Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.

CMS Clarifies That 86580 Covers Test Only

The first concern comes from misconceptions regarding what the TB skin test fees include. "Many physicians have always understood or interpreted the TB skin test code to include the reading, so the idea of separately coding for that reading seems 'unnatural,'" Moore says.

86580 stands alone: This misunderstanding is now a thing of the past. "Payment for 86580 (Skin test; tuberculosis, intradermal) includes the administration of the test only," CMS staff stated in an e-mail to Moore clarifying the skin test code. When a provider sees a patient in a separate face-to-face encounter to discuss the results, Medicare will pay for the test result interpretation with 99211 (Office or other outpatient visit for an established patient ... typically, 5 minutes are spent performing or supervising these services), according to CMS.

Interpretation Is Not Automatic

You can separately bill 99211 because not all patients return to have the test results read. Although the patient is supposed to return to have the test area checked, not all patients actually do (especially those who see no skin changes). CMS'e-mail concurs with this nonautomatic interpretation visit, stating, "Reading of the test results ... is generally performed two-three days following the intradermal test in the office." The agency recognizes that the healthcare provider doesn't always perform the reading.

The reasons for not returning to the office vary. For instance, the patient may not return because his spouse is a nurse, the patient knows what a negative or positive result looks like, or he may simply forget about the visit. Because the reading is not automatic, CMS does not include the interpretation in the test fee, so you can separately bill for it. Next, you will have to consider whether you want to charge for this service.

Think About PR

Despite these reasons, billing 99211 for the interpretation is still sticky for patient relations (PR) because billing the nurse code may trigger a copayment. Fees usually range from $5 to $30, but not all managed-care companies require a copayment for a nurse visit.

"Be sure to check your contracts specifically," says Jaime Darling, CPC, certified coder for Graybill Medical Group in Escondido, Calif. Although your software may trigger a copayment, be sure the patient owes one for a service that involves no face-to-face time with a physician. "You may be surprised," she says, adding, "many insurance companies don't charge copays for nurse visits."

Although it's technically correct to code for reading a TB skin test, it may be politically incorrect for your patients, especially if they have to pay a copayment for the privilege, Moore says. "Consequently, some physicians may decide that it's in the best interest of PR not to charge 99211 for reading a TB test."

Keep Practice Protection in Mind

Faced with financial pressures, your pediatrician may lean toward acceptable coding, rather than PR concerns. If this is the case, you should first inject some protection into your practice.

Be careful with payers: Before your pediatrician starts collecting the reading fee regularly, you should contact managed-care payers for their approval. And, include specific wording in your managed-care contracts that allows separate payment for the TB test reading. If you get the policy in writing, you'll protect your practice in case an auditor questions your billing method.

Consider Documentation Requirements

You should also ensure that your practice follows the basic 99211 reporting rules. To bill 99211 for a TB skin test reading, the clinician, such as the office nurse, should document why he saw the patient, the results, and any relevant follow-up, Moore says. For example, the chart note may read: "Patient seen to read TB skin test administered on (date); test results neg." Or "Patient seen to read TB skin test administered on (date); test results pos. Patient will return for evaluation and management."

"The American Academy of Professional Coders recommends the following documentation for billing a 99211: date of service, chief complaint and/or reason for the visit, service provided and/or information conveyed to the patient, appropriate vital signs, and signature of the nurse or other provider," Darling notes.

You should check with individual payers for their policies concerning 99211 billing requirements. Some insurers may mandate that the physician see the patient. Others may allow a nurse or other ancillary staff to qualify for billing 99211.

Sort Out Financial Versus PR Concerns

Armed with these facts and recommendations, let your pediatrician decide the course he would like to follow. These endorsements may encourage physicians to bill for the service based on the financial pressures they face. Or, "In many cases, patient relations will be far more valuable than the fee received for reading an occasional TB skin test," Moore says. You may also want to review CMS' response, available online at www.aapediatrician.org/x16698.xml.