Pediatric Coding Alert

Tighten up your coding for these common services to ensure you aren’t losing money.

If you’ve found that your practice has collected less money in the first quarter of 2014 than previous years, you’re not alone. Several practices have contacted Pediatric Coding Alert to ask for billing and collections tips in light of receiving lower pay this year. However, not all income issues are related to billing problems—in reality, the issue could be how you’re coding your services.

Consider the following five tips to ensure that you are coding accurately and therefore collecting the most accurate payment amounts this year.

1. Report 99211s Under On-Duty Physician

When a service such as a nurse visit (99211, Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified healthcare professional) is billed incident to the physician, make sure you file the claim under the supervising physician’s name. During a government audit performed of Medicaid and Medicare claims, the Office of Inspector General found that many practices are billing incident to services under a physician’s name who was not on the premises during the encounter.

Often, practice management systems use the name of the physician of record rather than the supervising physician when billing services. This arrangement makes allotting finances between physicians easier, but it causes incident to criteria to appear to be unmet. “Incident to” requires that the supervising physician is directly available, generally considered to be in or immediately adjacent to the office suite.

2. Support Unrelated Postop E/Ms With Modifier 24

Some minor procedures, for instance, wart removal (17110, Destruction [e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions) include a designated number of global postoperative days, such as 10 for 17110 wart removal, per the Resource Based Relative Value System (RBRVS). Private payers that use the Medicare Physician Fee Schedule and RBRVS include related E/M visits that occur during this period in the procedure’s values.

To bill an unrelated E/M service during a global period, make sure you’re using modifier 24 (Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period) on the E/M service. For instance, a pediatrician treats a patient for reduction of subluxed radius (24640, Closed treatment of radial head subluxation in child, nursemaid elbow, with manipulation), which has a global period per RBRVS of 10 days.

The patient returns two days after the nursemaid elbow reduction with vomiting and fever. The physician diagnoses infectious gastroenteritis (009.1, Colitis, enteritis, and gastroenteritis of presumed infectious origin) and selects 99213 for the E/M service (Office or other outpatient visit for the evaluation and management of an established patient ...). The coding should support the E/M service as unrelated to the radius reduction’s global period by appending modifier 24 to 99213.

3. Don’t Write Off Sibling Checks

Every pediatrician has been there—you’re giving a patient an exam when the parent tells you that the sibling (who is present) has also exhibited symptoms of an illness and asks you to just “peek into her ears” or elsewhere while she’s in the room with you. Many physicians write off this “quick look,” but you shouldn’t.

Looking at the second child usually involves pulling her chart and completing an encounter form. All of these actions indicate that you performed an E/M service, albeit one that was unscheduled.

You would certainly charge for such a separately scheduled service, so you should treat the additional exam at the time of another patient’s scheduled appointment the same way: Document and bill the history, examination and medical decision-making. Tell the parent you would be happy to evaluate the patient, and that you will pull the chart and arrange for a separate visit for the child. 

Assign the appropriate-level office visit code (such as 99212, Office or other outpatient visit for the evaluation and management of an established patient) and collect the designated copay, such as $25, in addition to the office visit for the other child (for instance, 99392, Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]).

4. Collect for Services—Even When Inconclusive

Working with children has inherent issues that don’t exist in other specialties, and chief among them are kids who may not have the patience to complete a service or test. But when a pediatrician spends time attempting to get a result, you should still be able to collect for trying.

For instance, suppose the doctor attempts a hearing and vision screen but cannot obtain the desired results. You can report the screening codes if the pediatrician fully documents the attempt and the reason she could not complete the tests, such as an uncooperative child. To indicate that the physician attempted a thorough result but eventually gave up, attach modifier 53 (Discontinued procedure) to the test code.

For instance, if the pediatrician tried to test the child’s hearing but she refused to raise her hand or to indicate she heard a noise, append modifier 53 to 92551 (Screening test, pure tone, air only). For an incomplete attempt of a vision screen, attach modifier 53 to 99173 (Screening test of visual acuity, quantitative, bilateral). 

You can link the screening test with V20.2 if it is part of the preventive medicine service, and it would not be subject to a copay or deductible. Some plans want you to append modifier 33 to the CPT® code to indicate that no copay or deductible applies to the visit. Alternatively, you can link 92551 to V72.1 (Special investigations and examinations; examination of ears and hearing) and 99173 to V72.0 (… examination of eyes and vision). The V codes indicate a reason for the encounter. 

5. Consider Charging for Parent Meet and Greet Visits

Expectant parents or parents considering adoption may want to interview your practice before their baby is born, but since the baby isn’t yet present, it can be hard to code these services, leading many practices to treat them as “freebies.” Although every office should create its own policy for these visits, you may consider charging for the services under certain circumstances. 

There are no standard CPT® codes for prenatal or pre-adoption visits, although the ICD diagnostic codes do exist. Those codes are V65.19 (Other person consulting on behalf of another person) under ICD-9, and in ICD-10 Z76.81 (Expectant parent(s) prebirth pediatrician visit). 

Some practices have success reporting the visit under the mother’s insurance using a preventive medicine counseling code (such as 99401-99404) linked to ICD-9 code V65.11 (Pediatric pre-birth visit for expectant parents).

If the mother or the fetus has any existing symptoms or a specific illness, you’ll report a code from the 99201-99215 series instead, since these codes more accurately describe a problem-focused visit. This should be billed to the mother, as the fetus/infant is not yet a patient or on the insurance policy.

If you choose bill this way, you should tell the family ahead of time that you’ll be billing for the visit and that they may be subject to a copay or deductible, since some parents may be surprised to pay anything for these visits. In addition, some insurers won’t reimburse you at all for these visits.

In other cases, it’s possible that the ob-gyn has identified a problem with the fetus and has asked for your opinion. For insurers that still accept consultation codes (99241-99245, Office consultation for a new or established patient ...), you can report the appropriate code from this range with a written report back to the ob-gyn if the ob refers the patient to you and asks you to meet with the patient. This consultation would again be billed under the mother if the baby is still in utero.

Some pediatricians simply consider doing meet-and-greets as good public relations (PR) and consider them a practice builder, since these visits could lead to the patient joining your practice, but many limit the visits to 15 minutes. In cases where the parents take up more than a pre-set amount of time (often 40 minutes), the practice may charge a flat fee.