Pediatric Coding Alert

File a well-written appeal to collect your due.

Even if you follow our advice to the tee, you might still face challenges collecting from your payers when you perform other services with a preventive medicine visit. But before you give up on getting paid, try these three tactics.

1. Appeal With CPT® Guidelines

Take advantage of your CPT® manual if you appeal other procedures, such as screenings, with preventive medicine service bundles. CPT® considers screenings distinct and does not include them as part of a preventive medicine service. The supporting language is in the CPT® Preventive Medicine Guidelines.

Good idea: Indicate that you are attaching supporting documentation showing CPT's non-inclusion of screenings with preventive medicine codes. Include a copy of CPT's preventive medicine services introductory notes with your appeal letter. Highlight the final paragraph, which states, "Immunizations and ancillary services involving laboratory, radiology, other procedures or screening tests identified with a specific CPT® code are reported separately. For immunizations, see 90460-90474 and 90476-90749."

Tip: When appealing a vision-screening bundle, also include 99173's entry, which reiterates that the screening is not included in a preventive medicine service. Highlight the second sentence of 99173's parenthetical instruction, which indicates, "Other identifiable services unrelated to this screening test provided at the same time may be reported separately (such as preventive medicine services)."

2. Include AAP Support

You could also obtain a letter of support from the American Academy of Pediatrics (AAP). In the appeals tools section of the AAP's Web site, members can find a letter that states screenings aren't inherent in preventive medicine services and should be separately paid.

Tip: Build a ready-to-go screening with preventive medicine service appeals packet. Include these three items:

• a fill-in-the-blank appeal form letter, either based on successful appeals you've written in the past, or using a template from your professional association
• a copy of CPT's preventive medicine service introductory notes
• a copy of the chart showing that the procedure was performed separately and documented from the preventive medicine visit.

Is appealing worth it? Over time, continued appeals will support changes in the coding edit that payers use, so aggressively appeal when necessary.

3. Check Insurer's Inclusion Reason

If your appeals efforts fall flat, take heart: Your payment search is not over. The AAP and many state chapters also have "hassle factor" forms for you to complete related to recurring problems of this type with insurance companies. They will then pursue issues with national payers through the Pediatric Private Sector Advisory Committee, and, at the state level through the state pediatric councils.

Do this: Ask the insurance company representative, "Why doesn't the plan pay for a screening with a preventive medicine service?" When the insurer's plan considers the screening a covered service (but as bundled or included in the preventive medicine E/M code), you can't bill the parents. But if the plan treats the screening as a noncovered service, you can balance-bill the guardians.

How it works: Some developmental-screening denial remittance statements indicate 96110 is not a covered service, which leaves the screen to the patient's responsibility.

Good idea: Have the patient or the patient's guardians sign an advance beneficiary notice (ABN). The form should indicate that the individual understands that he will be responsible for paying for a noncovered service.