Pediatric Coding Alert

Here's how to appeal improper benefit allotments

You'd better perform your own preventive medicine service tallies, or private payers could short your patients' well visit limitations.

That's exactly what Aetna does when a child misses scheduled immunizations and requires a nurse visit at the make-up encounter. "Aetna is applying CPT 99211 s to patients' well benefits," says Heather Zambrana, billing and collection manager at Farrell and South Riding Pediatrics in South Riding, Va.

Most payers set up their systems to count services linked to V20.2 (Health supervision of infant or child; routine infant or child health check) toward a child's allotted preventive medicine services. Suppose a mother brings in her child for her 2-year-old annual exam. You report 99392 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]) with V20.2. The insurer then applies the well visit to the child's annual benefits.

How Aetna works: When a pediatrician doesn't administer a child's immunizations at the preventive medicine service due to an illness, a vaccine shortage or some other reason, Aetna counts the nurse visit as a preventive medicine service. The insurer considers the need for a prophylactic V code (such as V03.81, Hemophilus influenza, type B) as a routine child health check diagnosis, Zambrana says. "But V20.2 goes with a well visit code (99381-99397), not a sick visit code (99211)."

Problem: When the pediatrician performs the child's second annual well check, Aetna denies the visit. "The insurer thinks the patient has used up her benefits," Zambrana says.

Solution: Appeal the denials. Zambrana wrote Aetna a letter explaining the problem and also copied the affected parents. If Aetna or another payer is counting 99211s toward preventive visit limits, send the insurer a letter appealing the preventive medicine denials. Explain that the company should only count preventive medicine codes (99381-99397) linked with V20.2 toward a patient's well visit allotment.