Pediatric Coding Alert

Which item is your well-check inclusion appeal pack missing?

Before you throw in the towel on getting paid for a hearing, vision or developmental screening on the same day as a preventive medicine service, try four tactics.

1. Put Modifier 25 on the E/M Service

When an insurer considers a screening service included in a preventive medicine service, you can try using modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) with 99381-99385 (new patient preventive medicine service) or 99391-99395 (established patient preventive medicine service). "However, CPT does not require modifier 25 on claims involving a CPT medicine code and E/M service," says Richard Tuck, MD, FAAP, medical director of quality care partners for PrimeCare of Southeastern Ohio in Zanesville. Therefore, you don't technically need modifier 25 when the pediatrician also performs a screening during a preventive medicine service, such as:

• hearing screening (92551, Screening test, pure tone, air only)
• vision screening (99173, Screening test of visual acuity, quantitative, bilateral)
• developmental testing (96110, Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report).
 
Some payers may allow payment if you use this method. "We're seeing more and more insurance companies that want a 25 on the preventive medicine service when coding a screening," Tuck says.

Beware: Revisions in CPT 2008 to modifier 59 (Distinct procedural service) put an end to using 59 on the screening to designate it as distinct from the E/M service. Look for details on these changes--and what to do for payers that don't follow suit--in next month's Pediatric Coding Alert.

2. Appeal With CPT Guidelines

Take advantage of your CPT manual if you appeal screening with preventive medicine service bundles. CPT considers screenings distinct and does not include them as part of a preventive medicine service, Tuck says. "Your appeal letter should point that out."

Good idea: Indicate that you are attaching supporting documentation showing CPT's non-inclusion of screenings with preventive medicine codes. Include a copy of CPT's preventive medicine services introductory notes with your appeal letter. Highlight the final paragraph (on page 32 of the CPT 2008 Professional Edition), which states, "Immunizations and ancillary services involving laboratory, radiology, other procedures or screening tests identified with a specific CPT code are reported separately. For immunizations, see 90465-90474 and 90476-90749."

Tip: When appealing a vision-screening bundle, also include 99173's entry, which reiterates that the screening is not included in a preventive medicine service. Highlight the second sentence of 99173's parenthetical instruction, which indicates, "Other identifiable services unrelated to this screening test provided at the same time may be reported separately (such as preventive medicine services)" (page 436).

3. Include AAP Support

You could also obtain a letter of support from the American Academy of Pediatrics (AAP). Members can find in the appeals tools section a letter that states screenings aren't inherent in preventive medicine services and should be separately paid, Tuck says.

Tip: Build a ready-to-go screening with preventive medicine service appeals packet. Include these three items:

• a fill-in-the-blank appeal form letter. Members can access appeal letter templates from www.aap.org/moc, link to "Private Payer Advocacy."
• a copy of CPT's preventive medicine service introductory notes
• the AAP's letter of support. You can find an AAP recommendation letter on separately reporting 96110 from a preventive medicine service code at www.medicalhomeinfo.org/screening/DPIP/96110appealsletter.pdf.

Is appealing worth it? "We have a lot of insurers that bundle 96110 into the primary procedure," says Tracy Russell, CBCS, with Carroll Children's Center in Westminster, Md. Repeated appeals will sometimes result in payment, she says.

Important: Over time, continued appeals will support changes in the coding edit that payers use, Tuck says.

4. Check Insurer's Inclusion Reason

 If your appeals efforts fall flat, take heart: Your payment search is not over. "In the short term, pediatricians will need to come up with their own strategies for billing or not billing the parents," says Robert W. Hered, MD, chief of the ophthalmology division at Nemours Children's Clinic in Jacksonville, Fla.

Do this: Ask, "Why doesn't the plan pay for a screening with a preventive medicine service?" When the insurer's plan considers the screening a covered service (such as bundled or included), you can't bill the parents, Tuck says. But if the plan treats the screening a noncovered service, you can balance-bill the guardians.

How it works: Some developmental-screening denial remittance statements indicate 96110 is not a covered service, which leaves the screen to the patient's responsibility, Russell says. "I then have to explain to the patient about the code because insurers tend to blame the denial on the 'coding' and refer the customer to us."

Good idea: Have the patient or the patient's guardians sign an advance beneficiary notice (ABN), Tuck says. The form should indicate that the individual understands that he will be responsible for paying for a noncovered service.