Pediatric Coding Alert

When a child sees a nursefor just an injection or a weight check, for examplethe fee for the visit is usually low, $26 to $36 according to the Physicians Fee & Coding Guide (sometimes lower if the patient is with a managed care plan that gets a discount). A patients co-pay may well end up covering most of the visit, which is coded using CPT 99211 . Some practices feel hesitant about asking for a co-pay under these circumstances.

Regardless of what the nurse does, if you charge for an office visit, you should, in most cases, bill the patient a co-pay, our sources say. Here are their reasons, along with a few situations in which the co-pay may not apply:

1. It is required by contract. You should check with your managed care contracts, but most, if not all, require you to collect a co-pay every time you bill for an office visit, says Daria Phelps, insurance manager for Wildwood Pediatrics, a four-pediatrician, two-nurse practitioner practice in Essex, CT. If there is an office visit, a co-pay is required by the insurance company, says Phelps.

Tip: Its important to consider a key purpose of co-pays. The insurance company uses a co-pay to discourage
overutilization. If you come between the company and its co-pay policy, you will be seen as interfering with its cost controlsnot to mention possibly violating the terms of your contract.

2. Forget the co-pay for immunizations included in preventive care visit. Sometimes, a child comes in for a well visit, but has a minor health problem which prevents immunizations to be given at that time. So, the child comes in the next week, just for the shots. Is a co-pay collected this time? No, says Phelps. If the shots were supposed to be part of the physical, theres no co-pay. Thats because most plans, to encourage patients to get to their well visits, do not permit physicians to collect co-pays for physicals.

3. Newborn weight checks. This is another common example of nurse visits that do require co-pays. Phelps does collect a co-pay for these visits.

4. Offering an alternative: free nurse visits.
If you really dont want to charge a co-pay for nurse visits, your only option is to not charge for the visits at all. This is the strategy used by Jan Taylor, assistant office manager for Childrens Medical Group, a 13-pediatrician practice in Mobile, AL. We dont bill for any nurse visits at all, explains Taylor. If patients come in just for an immunization, the practice bills for the administration of the shot, she says.

5. Explaining the co-pay. Dont let worries about how to explain the co-pay to parents keep you from charging it. There is a simple solution: just explain that co-pays are based on the patients presence in the office, regardless of what services are provided. Whether an expensive procedure or a minor one is performed, the co-pay is the same.

A reminder: The 99211 code could be used by a pediatrician as well, if the visit were very simple. However, it has come to be known as a nurse visit. According to CPT, 99211 is for the evaluation and management of an established patient that may not require the presence of a physician. The problems are minimal and about five minutes are spent performing or supervising the service.

Note: PCAs sister newsletter, Pediatric Practice Management, featured an article on collecting co-pays on page 33 in the May 1998 issue. For information about purchasing this issue or obtaining a subscription to the newsletter, call 800/508-2582.

Pediatric Examples of the Utilization of the Nurse Visit Code Office visit for a 9-year-old established patient, successfully treated for impetigo, requiring release to return to school. Outpatient visit with 19-year-old male, established patient, for supervised drug screen. Office visit with 12-year-old male, established patient, for cursory check of hematoma one day after venipuncture.