Pediatric Coding Alert

In the old days, pediatric practices could afford to absorb the costs of calling pharmacies with prescriptions. Now, because of managed care, this service is becoming burdensome and costly. Below several pediatricians and a practice manager share their tips for dealing with this costly dilemma.

Bring the Patient Into the Office

William B. Rogers, MD, a pediatrician in Akron, OH, has a policy that the parent and/or patient come in to his office for a prescription. The parent brings the child in, I get the story, and if needed I write a prescription, Rogers tells us. He codes the visit CPT 99211 or 99212. When he uses 99211, the nurse can even take the history, he adds. Its important that the nurse has some face-to-face time with the patients, and that her notes reference any prior phone calls. The nurse can even save time and get the history over the phone before the patient comes in to be seen by the physician, explains Rogers. With 99212, Rogers tells us its usually for about a 10 minute visit with the patient and parent.

Ive never had any trouble getting reimbursed by insurance companies for this process, the pediatrician adds.

Of course, there are parents who object to having to come into the office for a prescription. For example, when the parent believes their child needs an antibiotic, and asks to have it phoned in. I tell them I refuse to phone in a prescription for antibiotics without seeing the child, he says. Some patients also run out of Ritalin and call the doctor to request that a refill be phoned in. I tell them I cannot legally phone a Ritalin refill in without seeing the child, says Rogers, noting that Ritalin is a Schedule II drug, the most restricted category of legal drugs.
For years, Rogers has used 99211 or 99212 for Ritalin refills, with the patient coming in for the prescription. This way I only need to reexamine every three to four months, he says.

Ritalin refills are only for 30 days, and at the end there needs to be some information obtained about whether the medication is working, and whether there are side effects. Those two questions can be answered over the telephone, which is how most offices do it, states Joel Bradley, Jr, MD, FAAP, a member of the AAPs RBRVS committee. The telephone is the most efficient way to get that information, although it doesnt improve your overhead.

Bradley, who practices in Clarksville, TN, says the key question is whether seeing a patient to refill a prescription enhances quality of care. If it does, then you should go ahead and do it, and code accordingly (92111 if a nurse sees the patient, 92112 if a physician does). Look at it as a way to provide a better service, says Bradley. If theres reimbursement, so be it.

Bill for the Call

Another view comes from Karen Dench, CMM, office manager for Gerald F. Sturgeon, MD and J. Kathleen Moore, MD of Louisville, KY. Dench recommends that 99371 be used. This code is for, among other things, a Telephone call by a physician to a patient or for consultation or medical management or for coordinating medical management with other health care professionals (e.g. nurses, therapists, social workers, nutritionists, physicians, pharmacists)...

Like Rogers, Denchs office does not call in any antibiotics without seeing the patient. But there are some prescriptions that we do call in, such as for diaper rashes or colds, she adds. The front office staff calls them in after the doctor writes down what he wants.

I believe a practice is well within its rights to bill for making these calls, Dench says. You have to protect your business interest and income. However, she adds one caveat: just because theres a code doesnt necessarily mean the insurance company will pay.

A word of warning: before you use 99371, consider this -- most carriers may well refuse to pay. And if they don't pay, you will be generating a great deal of billing to parents and possibly make them angry.

By the way, if you do ask the questions about the effectiveness and side effects of medication over the telephone, there are codes you can use: 99371, 99372, and 99373. However, as Bradley notes, these codes arent generally being reimbursed by managed care.