Pediatric Coding Alert

Sometimes called a nurse visit, 99211 is a valuable code for pediatrics. Its the lowest level office visit for an established patient, and the only E/M services code that doesnt require the presence of a physician. It is most commonly used in pediatrics when a child comes in for a urine test, a rapid strep test, or an immunization.

The only problem with using CPT 99211 is that you must collect a co-pay from the parent. This can be a large public relations problem. Lois Avery, business manager for Pediatric Associates of Connecticut, a five-pediatrician, one-nurse practitioner practice in Waterbury, CT, sums up the problem this way: Theyre not seeing the doctor, so they dont see why they have to pay anything. Thats the viewpoint of many parents. The perspective of the insurance company is quite different: if youre billing the insurance company, you better collect a co-pay. Its in your contract.

Many pediatric practices cope with this problem by not using 99211 at all. They simply write off the entire nurse visit. If you are one of these practices, take a look at the number of such visits you have. You may want to reconsider; Averys solutions to 99211 co-pay problems may help you make that decision.

Averys practice does collect a co-pay for 99211, which is used quite frequently. We do a lot of strep tests, she says. Were open seven days a week, and we have a lot of patients. Using 99211 and collecting the co-pay has really paid off. But there have been some challenges along the way.

Resolving Parent Opposition

The first challenge occurred when the policy first began, and parents called their insurance companies to complain about having to pay a co-pay. `Why do I have to pay a co-pay for a strep test?, theyd ask, says Avery. Then the insurance company would tell them, `You dont. The fact is that the strep test, indeed, does not have a co-pay. But the supervision of the nurse does, and thats what the 99211 is for, she explains.

If you decide to start billing 99211 for nurse visits and collecting co-pays, you may well run into a similar problem. Averys solution was to talk to the insurance companies. We told them that its not their business to tell us how to do our billing. This worked.

It is also essential that you collect the co-pays consistentlyno exceptions. We tell parents we would love for them not to have to pay a co-pay, Avery adds. But we explain that it would be considered fraud if we didnt charge it.

Avery also has a notice posted in the waiting room that explains the policy to patients. The notice begins: Due to the way managed care companies reimburse us, it has become necessary to collect a co-pay when we do procedures (for example, rapid strep tests), It goes on to say that while the practice could bill insurance companies for tests in the past, managed care now separates the cost of the test and the cost of an office doing a test. Using the appropriate code means a co-pay must be collected. We were considering writing off the co-pay for our patients, but unfortunately, we would not be in compliance with our contract with your insurance company, the notice states, adding that this would be considered fraud. Finally, the notice says that it is impossible to accept a lab payment from an insurance company that is less than what it costs to actually perform the test.

There is another way of using 99211, collecting
co-pays and having no trouble with parents at all. Its to have the pediatrician see the patient. This is what Kathy Giovanelli, office manager for Thomas Etkin, MD and Jeffrey Hoogstra, MD of West Haven, CT does. The pediatricians usually use 99211 for very brief visits, such as ear rechecks, says Giovanelli.

Note: Giovanelli is planning on having the nurses start using 99211 in the future.