Pediatric Coding Alert

Although pediatricians aren't used to using HCPCS Codes , the level-two S codes offer potential coding and reimbursement for services that CPT does not define. When a pediatrician provides a service that CPT does not define, follow three steps to use HCPCS level-two S codes to solve the reimbursement hitch.

1. Know Who Accepts S Codes

Blue Cross/Blue Shield (BCBS) developed the S codes to report drugs, supplies and services. Use these codes when no CPT code exists, when the HCPCS code is more specific, or when the third-party payer requires it. The codes are exclusively for use with private payers. Medicare does not accept them.

"When there is no CPT code that applies, we always check the HCPCS for an alternative code," says Catherine Hudson, RMA, RPT, insurance and billing collections, Cumberland Pediatrics, Marietta, Ga.

If an S code appropriately describes the service provided, make sure the carrier will accept it. Read material such as newsletters and carriers' local medical review policies to stay knowledgeable, recommends Cathy Gasiewicz, RHIT, Botsford Clinic System Compliance Coordinator, Farmington Hills, Mich. "It's also important to review the codes in the insurance fee or payment schedule," she says. "If the code is not listed, it's usually not payable."

2. Look for Common Areas of Use

Coders often have problems billing for suture removal provided by a different physician. For these services, consider using a HCPCS code.

"To bill for suture removal by a physician other than the physician who originally closed the wound, we bill S0630 (Removal of sutures by a physician other than the physician who originally closed the wound) to BCBS of Michigan," Gasiewicz says. "To all other carriers, we report a problem-oriented E/M code (99201-99215), and link ICD-9 code V58.3 (Attention to surgical dressings and sutures) with it."

Note: For more on reporting sutures removed by another physician using an office visit code, see the September issue of Pediatric Coding Alert, page 71.

Use the same diagnosis coding for HCPCS codes as you would for the CPT code, Hudson points out. "There is no difference."
 

3. Create a System of Payer-Appropriate Codes

Using the codes that individual insurers recognize can help get claims paid on the first try. However, keeping track of the various codes to use for each carrier can pose a logistical nightmare. To solve this logistical problem, design an encounter form to help your pediatricians and billers keep the codes straight, Gasiewicz says. "Group the CPT or HCPCS code by the major insurance companies," she explains. Under the category of suture removal by different physician, the biller chooses from the following:

BCBS

ALL OTHER INSURANCE

Provided that you did the research described in step 2 and made a chart of your findings (step 3), carriers should not reject your claims. "If you have to appeal, send copies of the HCPCS book to prove that the code is not a deleted or an obsolete code," Hudson says.