Coding When Theres No Well-Child Coverage
Published on Fri May 01, 1998
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 [...]
