Pediatric Coding Alert

Private payer auditors will be targeting these pediatric practice error areas.

If you think as a pediatric practice you can ignore the OIG's 2011 Work Plan, be prepared for payback requests from your major payers.

Myth: As a pediatric practice, you don't have to pay attention to the services and procedures listed in the plan.

Truth: Although the Office of Inspector General's annual work plan recommends audit areas for Medicare contractors to focus on, private payers will include the high error items noted on the plan in their audits as well. To avoid having to pay back thousands in unsubstantiated or improperly coded services and procedures, do an internal audit so that you can bring your practice into compliance. Focus on these top error areas:

Support Unrelated Postop E/Ms With Modifier 24

Some minor procedures, for instance, wart removal (17110, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) include a designated number of global postoperative days, such as 10 for 17110 wart removal, per the Resource Based Relative Value System (RBRVS). Private payers that use the Medicare Physician Fee Schedule and RBRVS include related E/M visits that occur during this period in the procedure's values.

To bill an unrelated E/M service during a global period, make sure you're using modifier 24 (Unrelated E/M service provided during a global period) on the E/M service. For instance, a pediatrician treats a patient for reduction of subluxed radius (24640, Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation), which has a global period per RBRVS of 10 days.

The patient returns two days after the nursemaid elbow reduction with vomiting and fever. The physician diagnoses infectious gastroenteritis (009.1, Colitis, enteritis, and gastroenteritis of presumed infectious origin) and selects 99213 E/M service (Office or other outpatient visit for the evaluation and management of an established patient ...). The coding supports the E/M service is unrelated to the radius reduction's global period by appending modifier 24 to 99213.

Report 99211s Under On Duty Physician

When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of the physician) is billed incident to the physician, make sure you file the claim under the supervising physician's name. The OIG found that many practices are billing incident to services under a physician's name who was not on the premises during the encounter.

Often, practice management systems use the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. "Incident to" requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.