Pediatric Coding Alert

It happens every day in most pediatricians offices: a new mother is standing at the front desk with her five-day-old baby in her arms, happily handing you the clipboard with her family health and insurance information filled in. A quick glance tells you that her plan only pays for sick visits, but has no coverage for well visits (well-visit codes used by pediatricians would be 99381 - 99385 for a new patient, and 99391 - 99395 for an established patient). Not only does a newborn have six scheduled visits during the next year, but this is the new mother's first child, meaning that the pediatrician will be spending a lot of time talking with her about feeding, sleeping, crying, and other basic concerns. The pediatrician naturally wants to provide the necessary care, and to continue treating the child, but needs to do so economically and with consideration for the parent's finances. We called several office managers and a consultant to find out how they deal with this common situation. Some take a harder line than others, as can be seen.

1. Use a well-visit code if thats what you do. If its a true physical, with no complaints and no symptoms, you cant just make something up, says Jacqueline Thelian, CPC, a medical practice consultant based in Fresh Meadows, NY, who goes into pediatricians offices to make sure procedure and diagnosis codes are correct. Its all documented in the chart. You cant make up diagnoses. Thelian stresses that it isnt worth trying to do that, anyway. Its their license on the line, she says. Its not worth it for a few visits.

Tip: Thelian believes that with children, you usually do find a diagnosis, however. This is especially true with newborns, she says. But if you dont, then you dont. Period.

2. Dont forget the audits. In case of an audit, its very important that the chart match up with the superbill, says Pat Hartrich, business manager for Aquino, Hartrich & Hrab, a pediatric practice based in Williamsville, NY. If you have a six-year-old physical in the charts, thats what it has to say on the superbill.

3. Parents have to pay if the child is well. If it's a well visit, and they know they dont have the coverage, then they should know they have to pay, says Barbara Brenton, office manager for North Park Pediatrics, a four-pediatrician, one-nurse practitioner office in Bel Air, MD. We code it what it was and the parents are responsible. Hartrich agrees, saying that there is usually no argument from the parents over paying. We dont have trouble collecting, because they know from the outset that physicals arent covered under their policy, reports Hartrich.

4. Use an office-visit code if child is sick. However, if a significant problem is discovered during a well visit -- so significant that it requires extra decision-making on the part of the pediatrician -- then an office-visit code would be appropriate, says Brenton. It would have to be something significant, she notes. Not like a swollen ear drum. Examples of something that might surface during a well visit which could turn it into an office visit include a headache which has lasted for three weeks, severe constipation, abdominal pain going on for two months, eating problems, or excessive weight loss or gain.

5. When to use the -25 modifier. If a child comes in for a well visit and you find a significant problem, you can use the -25 modifier. CPT specifically allows for this, saying that if an abnormality is encountered or addressed in the process of conducting a preventive medicine services exam, and if the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then you should report the office visit, with modifier -25 attached. However, some office managers hate to use the modifier because, they say, nobody ever pays it. Insurance companies dont reimburse for it, Brenton says flatly. She had high hopes for the -25 modifier, but found that managed care companies usually only process the first code, and ignore the modifier altogether.

Tip: To facilitate reimbursement for the -25 modifier, try quoting CPT to these companies, which may just not have upgraded their computer edits.

6. Tell parents to ask for a rider. Sometimes its appropriate to tell the parent to go back to his or her employer and ask for a rider that covers well visits for children. Say theyre employed by a small firm, and most of the employees are in their 40s and 50s, explains Brenton, Its not worth it to the firm to buy a plan for everyone that includes well visits for children, just for one or two younger workers. But if the younger worker is a parent of your patient, why not recommend asking for a rider to the plan? Chances are the parent doesnt even know this is a possibility, and would be happy to know there is an alternative to paying for the well visits out of pocket. I recommend that they look into a rider if their insurance company doesnt pay for preventive medicine services, asserts Hartrich. This is especially important if theyre just starting a family.

7. Discounts for same-day pays. Parents who are paying for the visit on the same day get a 10-percent discount at Brentons office. This encourages them to pay promptly, and minimizes billing paperwork.

8. Free vaccines. Dont forget that all states participate in the federal Vaccines for Children program, which provides free vaccines for all children who are Medicaid-eligible, uninsured, American Indians or Alaskan natives, or underinsured. Underinsured means that their insurance companies do not cover immunizations.

9. If insurance denies well-visit compensation, send a copy of EOB to parent with a note. If an insurance plan doesnt cover well visits, the explanation of benefits (EOB) will say so. What Kay Shelton, office manager for William Lee Tift, MD of Macon, GA, does is to send a copy of the EOB along with a note saying that the insurance company has denied the claim, and, of course, a bill, which, in turn, means the parent is responsible for the balance. (The bill has the patients co-pay deducted from it, since Shelton makes it a practice to always collect co-pays and deductibles up front, rather than bill for them.)

10. Set a guideline for the pediatricians: Call them as you see them. Many parents actually ask the pediatricians if they can make a well visit a sick visit. They say, `My plan only pays for sick visits, when they bring a child in for a physical, says Shelton. If it ends up being a sick visit, then thats what it is. But if it ends up being just a physical, then its just a physical. This is the guideline that Shelton ended up setting: Call them as you see them. Regardless of what the patient was scheduled for, if the visit actually becomes a sick visit, then thats what it is coded.

(Note: Usually this sick visit is so significant that it is a 99214, says Shelton.)

Office Visit Codes:

99201 - 99205: new patient
99211 - 99215: established patient

Preventive Medicine Services Codes:

99381: New Patient, age under 1 year,
99382: New Patient, age 1 through 4 years
99383: New patient, age 5 through 11 years
99384: New patient, age 12 through 17 years
99385: New patient, age 18-39 years
99391: Established patient, age under 1 year
99392: Established patient, age 1 through 4 years
99393: Established patient: age 5 through 11 years
99394: Established patient: age 12 through 17 years
99395: Established patient, age 18-39 years

All preventive medicine services codes include:

--comprehensive history
--comprehensive exam
--counseling/anticipatory guidance/risk factor reduction interventions
--appropriate laboratory/diagnostic procedures