Pediatric Coding Alert

When the Health Care Financing Administration (HCFA) announced last spring that it would start focusing claims reviews on two codes, 99214 (office or other outpatient visit for the evaluation and management of an established patient) and 99233 (subsequent hospital care, per day, for the evaluation and management of a patient), pediatricians barely lifted their eyebrows. After all, this was Medicare, right? But now, some private payers are deciding that all 99214s should be downcoded to 99213s, unless pediatricians provide documentation up-front of all 99214s. But you dont have to put up with this. You can fight this practice in several ways:

1. Send the documentation. If you receive a letter from an insurance company saying that to code a 99214 you need to send all the documentation with the claim, but that if you prefer you can just initial right here and get paid for a CPT 99213 instead, dont sign off on the offer. Send in the documentation. This is what Richard H. Tuck, MD, FAAP, who practices with PrimeCare Pediatrics in Zanesville, Ohio, did. He got paid for every 99214, and the insurance company got so much negative feedback that it stopped the practice. It wasnt worth it because the company had to go over all the documentation, see that it justified the 99214 claim, and pay it anyway. The pediatrician thinks its easier for him to just downcode himself, because then he wont have to be bothered with the insurance company, says Tuck. But this is giving up.

2. Go over your documentation and appeal. For insurance companies that are simply downcoding your claims individually, you need to go back to the chart and scrutinize your documentation, says Charles A. Scott, MD, FAAP, a pediatric coding expert who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J. If you can justify a 99214, appeal, he says. Their denial is arbitrary and capricious. Its not as if they came into your office and looked at your chart, and then downcoded you. Scotts practice is very large 60 pediatricians so it was able to work out an agreement with Cigna, an insurance company that was routinely downcoding all 99214s. They arent doing that to us because we discussed it with them and voluntarily agreed for them to come in and go over our charts. Scotts practice now has a special dispensation to bill 99214s to Cigna. Dont expect to be able to do this if you are a smaller practice, however.

3. Dont downcode yourself. Its well known that some pediatricians are downcoding themselves because they dont want to get audited, says Curtis J. Udell, CPAR, CPC, president and CEO of Emphysys, a physician reimbursement, compliance and practice management consulting firm in Cumming, Ga. This isnt the right way to respond to the problem. Rather, you need to code appropriately, and fight for the correct code using your documentation.

Udell notes that one interesting development is that some state insurance commissioners are not allowing insurance companies to assign CPT codes. The insurance commissioners say it is tantamount to practicing medicine without a license, and they dont allow it, says Udell, noting that Georgia is such a state. Finally, Udell notes that increased scrutiny of charts means that documentation can work for you.

4. Negotiate. Richard H. Schwartz, MD, a pediatrician who practices in Vienna, Va., says its all very well to appeal and fight, but it takes a lot of time. Is it really worth it? he says. I will code a 99214 for an asthma patient in distress, or if I had to do a rectal examination for abdominal pain, or for some really complex case with multiple problems. It would be nice to win fights with insurance companies, so that you can have the higher payments, but I dont know if its worth the time. It would be better so say to them, You have downcoded me 10 times in the past year. Eight of those times I fought back and won. So why dont we save the fight in the future. Out of the next 10 codes, you can downcode two. This way, says Schwartz, nobody loses.