Pediatric Coding Alert

Keeping your practice from taking advantage of the so-called E/M "loophole" is a little easier if you offer alternative safer ways to find additional income and root out revenue robbers.

"As of 2006, nearly 60 percent of doctors polled by the American College of Physician Executives said they had considered getting out of medicine because of low morale, and nearly 70 percent knew someone who already had," according to "Falling-Down Professions" in the Jan. 6, 2008, New York Times. The business side is strangling the professional calling.

Take heart: Revenue might be lurking in your everyday coding and expenses. Try these tips to tap more charges and reduce losses.

You might be leaving money on the table if you rely on office staff who are unfamiliar with coverage policies to input your codes. "Pediatricians can capture revenue by having someone who knows the insurance plans review the charts and superbills daily to be sure that all charges have been captured," says Janet McDiarmid, CMM, CPC, MPC, of St. Petersburg Pediatrics, which has eight offices serving Pinellas County, Fla.

The problem: When physicians mark superbills, many charges are missed, McDiarmid says. "The person doing the data entry is usually not a certified coder and does not have knowledge of what is covered and what is not."

The reviewer should also make sure there is proper documentation for services rendered. "It is amazing the charges I capture by doing this analysis," she says.

Myth: Think having a skilled reviewer is outside your budget? The position will likely more than pay for itself. McDiarmid captures significant dollars that the practice would have missed, and this "discovered" amount has easily paid for her salary. The role also ensures accurate coding, which would provide more protection in the event of an audit.

Denials could be heading your way, and the ticket to payment could be simply a digit away. Make sure that you assign the correct diagnosis to ancillary tests.

Horror story: McDiarmid visited a practice where billers were very upset that insurers were denying their chest x-rays (71020, Radiologic examination, chest, two views, frontal and lateral). They had the correct CPT code, but they were using the diagnosis code for vaginal discharge (623.5, Leukorrhea, not specified as infective) instead of the x-ray sign or symptom (such as cough, 786.2) or diagnosis, costing them about $31.99 per denial (0.84 total RVUs x 38.0870 using the 2008 Medicare Physician Fee Schedule).

Lesson learned: In pediatrics, payers are denying ancillary tests, such as strep tests, simply because "the ICD-9 code is not correctly assigned to the appropriate service," McDiarmid says. Double-check to make sure your system has 87880-QW (Infectious agent detection by immunoassay with direct optical observation; Streptococcus, group A; CLIA waived test) linked to:

• 041.01 (Streptococcus; group A) for a positive test or

• an appropriate sign or symptom, such as pharyngitis (462), for a pending or negative result.

When you align your CPTs and ICD-9s for all performed charges, you should be familiar with your cost. To identify the cash cows from the revenue robbers, get a hold of an income and expense report and a revenue generation report by CPT code and RVU, says Kevin Perryman, administrator at the office of Teri Perryman, MD, in Kerrville, Texas. Then do this procedure:

Step 1: Divide total income by total RVUs to figure out average income per RVU.

Step 2: Divide total expenses by total RVUs to figure out average cost per RVU.

Step 3: For each CPT code, multiply that code's RVUs by the above averages to determine the average income and cost per RVU for each CPT code.

Analysis: "Compare insurance reimbursement rates to the average income per RVU to see which ones are paying low," Perryman says. "Compare insurance reimbursement rates to the average cost per RVU to see which ones do not cover cost."

Next month: Find out what to do with this info.