Pediatric Coding Alert

Pediatricians often undercode and undervalue their services, says Richard H. Tuck, MD, FAAP, founding chairman of the AAPs RBRVS PAC. To halt their tendency to use too many second-level codes and not enough third-, fourth- and fifth-level codes, pediatricians can look to the 1999 report on utilization, released by the American Academy of Pediatrics (AAP) late last year. The report shows that there is a leftward shift in utilization of evaluation and management (E/M) codes by pediatric practices, which means revenue is less than it should be. These codes should form a bell curve, with the middle of the bell on 99213.

According to the utilization report, pediatricians use 99213 more than any other code. A primary-care pediatrician codes visits with 99213 about 3,280 times a year, compared to 134 visits coded CPT 99211 , 905 visits coded 99212, 227 visits coded 99214 and 20 visits coded 99215. Pediatric subspecialists see fewer patients, but the statistics are similar, except that they code twice as many 99215 visits (53).

Median fees charged for these office visits for established patients, for primary care pediatricians and pediatric subspecialists combined, are $25 (99211), $40 (99212), $53 (99213), $75 (99214) and $110 (99215). The survey also breaks down fees per code by geographical region.

But the survey shows a disturbing trend. Each family of E/M codes should be a bell-shaped curve, with the greatest number of codes used in the middle. In other words, code 99213 should fall in the largest part of the bell curve, meaning it should be billed more often in that family of codes, and 99211 and 99215 should represent the extreme lower parts of the curve, meaning they are billed less often. If there are 905 visits coded 99212, there should be about 900 visits coded 99214 as well. But, according to the AAPs report, there are only 227 visits coded 99214.

The implication is that there could be a significant improvement in reimbursements for office visits if the bell-shaped curve were followed, says Tuck.

Reminder: To use a code, you must meet the codes criteria and documentation requirements.

To receive a copy of Pediatric Service Utilization, Fees and Managed Care Arrangements: 1999 Report Based on 1997 Data, contact the AAP, 141 Northwest Point Blvd., Elk Grove Village, IL 60007-1098;
(847) 228-5005.