Pediatric Coding Alert

Some insurers ardently believe that vision screening and audio screening are included in well visits. But as Mahmud M. Khan, MD, FAAP, of Manassas, Virginia acknowledges, the screening is time consuming. What should we do to better our chances of getting reimbursed? he writes.

Khan is working with Virginia Medicaid, but different insurance companies have different policies. We talked to two office managers about how they maximize reimbursement for vision and audio screens.

Different plans require us to bill separately for vision and audio screens, says Sheryl Cilento, office manager for liberty child and Adolescent Health Services, an 11-pediatrician practice in Jersey City, NJ.

No Code for Just Reading the Eye Chart

For vision screening, the question comes down to what kind of screening youre doing. If youre doing just the eye chart, theres no CPT code for it, says Cilento. Its just part of the well visit. Medicaid wont pay for vision screening done using the eye chart alone, Cilento says.

If, however, you are doing visual fields, there is a code: CPT 92081 . This is for a unilateral or bilateral visual field examination, with interpretation and report. The good news is that private insurers will pay for this. But the bad news is that New Jersey Medicaid wont, says Cilento. We continue to use the code, because we want them to know what were doing, she says.

I use 92081, which works sometimes, and sometimes doesnt, says Lucy Rocha, insurance coordinator for Island Pediatrics, a two-pediatrician practice in New York City. Some insurance companies wont pay for another specialty to use these codes, she adds, noting that 92081 is an ophthalmological code. If they dont pay, I just write it off.

The three practices we spoke to for this story have either mixed or good results using 92081 with private managed care.

Not in Addition to Well-Visits

But the real problem occurs when you try to bill for these screens in addition to a well visit; this is the case for private carriers as well as Medicaid. For example, if you do an audio screen as part of the well visit, Medicaid wont let you add it on, our sources say. Unless theres a way to use the modifier -25, you cant do it, Cilento says. Basically, if the office visit isnt separately identifiable, and well visits are not, you cannot bill for a well visit and screen on the same day.

Rocha also gets reimbursed for audio screens by not doing them as part of well visits. We do the audio screens when the school nurse sends children to their doctor for possible hearing problems, she reports. We use an office-visit codeusually 99213when the child comes in for the test, the insurance coordinator says. Then we also use 92551 for the audiometric test. The 92551 code is for a screening test using pure tone, air only (no bone). Calibrated electronic equipment is used. This is not like whispering or using a tuning fork. Both ears are tested. It is not necessary to add a modifier even though you are using two CPT codes, notes Rocha.

Cilento uses a machine called the Pilot Audiometer, which is designed specifically for screening young children for hearing loss. For the test, the child puts on headphones and listens to a friendly voice ask him or her to point to the pictures as the voice says the words. The words and pictures are simple, such as toothbrush, snowman, and cupcake. The words are said in descending decibel levels. When the machine is used this way, you should use CPT code 92583, for select picture audiometry. However, when you use this same machine for older children using pure tone, you should use CPT code 92551.

"Both of these codes seem to work very well in terms of reimbursement, says Cilento.