Pediatric Coding Alert

Pediatricians are often required to spend a great deal of time on the telephone answering questions for anxious parents. And while there are codes for this service (99371, 99372, and 99373), not all insurance companies pay for them. And therein lies the difficulty. If you only bill the insurance companies who pay for these codes, and provide the same service to other patients for free, youre not being fair to the insurance companiesand they will be the first to let you know that they consider that fraud. Third-party payers take an equally dim view of billing all insurance companies and then writing off the charge when it is denied. To further complicate the issue, some carriers do not allow you to bill patients for services which they dont cover. In addition to some form of write-off, the other two options are (1) to bill all insurance companies, and then bill the parents for the denied charge; and (2) to bill nobody and provide the service free, thinking of it as marketing or public relations. Whats the solution?

Consider It a Write-off

If you were to look at it from a strictly business standpoint, you would bill out these codes, because about half of the plans do pay, says Linda Kortanek, office manager for Northpoint Pediatrics, a six-pediatrician practice in Indianapolis, IN. Three years ago, Kortanek tried to do just this, but the experiment failed, because parents were infuriated when they received bills after the insurance company denied the claim. So, after having tried it the other way, Kortanek now considers the service a free benefit.

We couldnt only write it off for the patients in plans that dont pay, because that would have been discriminatory, she explains. We cant say to one plan, Because youre willing to fork over the money, were going to make you pay, and then say to another plan, Since you dont pay for telephone calls, were not going to charge you or your members for this service. The first plan thinks they should get the same benefit the second one gets, Kortanek explains. And you can see
their point.

So what Kortanek did was to bill all the plans, and then bill patients when plans denied the charge. But this created so much ill-will that we had to stop, she recalls. It was so inflammatory that it wasnt worth it.

Parents had many comments on the practice of billing, but the gist was that they view telephone calls as a benefit that should be free. And while some pediatricians do bill parents for telephone calls, Kortanek wouldnt want to risk it again. You cant get too cocky, she says. There are other pediatric practices around here. If we charge for something, and the competition gives it away for free, we could be in trouble. Finally, parents genuinely appreciate being able to talk to their pediatrician when they are in a panic. We look good when the doctors call back in the middle of the night, Kortanek notes.

Missy Ohler, business manager for Greensboro (NC) Childrens Doctor, had been considering billing insurance companies for these telephone codes. But then we found out that some plans will pay and some wont, she says. We decided not to charge because it would be discriminatory, unless the parents were billed, she explains.

Tip: On the other hand, there are other services, such as hearing screens, which insurance companies do not always cover, but for which Kortanek would always bill the parent. Parents understand when its something the doctor has done in the office with their child, she explains. And while some parents need to know why they are being billed for something, its usually easy enough to explain that their insurance plan wont pay for this, but it needs to be done. Sometimes parents even need to be told that they can ask their employers to get better insurance plans that do cover, for example, hearing screens. It does seem to make sense to them when we explain it, says Kortanek.

Peter Rappo, MD, FAAP, chairperson of the American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, thinks telephone counseling is a service parents want. If pediatricians are willing to bill insurers, why not bill the family as well, he asks. Rappo, who practices in Brockton, MA, believes parents dont mind paying for something as long as they value it. He tells parents who want to talk about behavioral issues, for example, but cant get into the office during office hours, that he will be glad to talk to them on the phone, but they have to pay. I say, Ill talk to you on the phone, but Im going to bill you for it. The calls usually take about half an hour, he says.

Include the Call in Next Office Visit

One of the problems is that reimbursement rates for office visits are no longer sufficient to cover the extra service of telephone calls, says Thomas Kent, CMM, former office manager for a pediatric practice, and principal of Kent Medical Management in Dunkirk, MD. Furthermore, says Kent, many practices are seeing an increase in after-hours calls due to the fact that both parents are working. When a matter is discussed over the telephone as a convenience to the patient, then the patient should be billed for this, says Kent.

But if billing the parent is really distasteful to you, Kent offers this solution: If the pediatrician has an extensive telephone call with a parent, and if the pediatrician documents the call, and if the pediatrician returns the documentation to the office and the patients chart, then the pediatrician could reference the call at the patients next visit, says Kent. Often the next office visit occurs within the next several days or weeks and the phone call is still relevant to the visit. The pediatrician reviews the phone call discussion with the parent at the office visit and references the phone call in the patients history, says Kent. The whole phone call is now part of the patients history for that day. Now that the phone call is a component of the entire office visit, you may have enough to justify the next higher level of service, says Kent.