Pediatric Coding Alert

Your coding pattern could cost you more than $30,000 annually. Implement this action plan to put your practice on the path to proper payment.

If you're like most pediatric practices, you're 99213-centric, with 70 to 80 percent of your established patient visits coded as 99213s, according to the Physician's Computer Company (PCC). The American Medical Association and Medical Group Management Association (MGMA) expect your established patient bell curve for level-three established patient visits to be at 65 percent to 67 percent and level-fours to comprise 7.2 percent to 12.5 percent of your visits.

Problem: "A University of Michigan survey found that 40 percent of correctly coded general pediatrician visits are 99214s," says Joel Bradley Jr., MD, FAAP, a pediatrician with Premier Medical Group in Clarksville, Tenn. So how do you move more of your 99213s into the higher-paying 99214 realm while still correctly coding these services?

Regularly compare the bell curves of your practice's pediatricians for differences, suggests Bradley. "You cannot manage well what you do not measure."

How to: If you find one physician has a higher distribution of 99212s, another has mainly 99213s and another has more 99214s, pull some progress notes. At your monthly teaching sessions, point out the differences. Do some sample chart note coding to highlight the nuances that make a common 99213 scenario, such as an otitis media case, a properly reportable as a 99214. "Many practices can gain up to $30,000 per year per physician by working on profiles ---and, when correctly motivated, physicians are both competitive and teachable," Bradley says.

Highlight how undercoding 99214s with 99213s can hurt your practice and each pediatrician's bottom line over the course of a year. If your office reports 500 visits for the year as 99213s that documentation actually supported as 99214s, you'd lose $33,750, estimates Victoria S. Jackson, practice management consultant with JCM Inc. in California. This figure allots $80 to 99214 and $50 to 99213 -- a $30 difference.

Now that you're convinced that your practice's coding distribution might not be up to snuff, show your pediatricians what coding properly will do for the practice's bottom line by plugging your sick visit numbers into a re-analyzer calculator. Do the math by visiting www.pcc.com/practmgmt/curve-calc.php.

These coding patterns should support medical necessity if you use appropriate diagnosis codes. For example, a case of straightforward otitis media (382.00) would generally constitute 99213, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare in Zanesville, Ohio. "But added systemic symptoms of fever (780.6) or vomiting (787.03) would support a medically necessary 99214 visit."