Pediatric Coding Alert

When a problem is found during a well visit, you may need to charge patients who expect to pay nothing.

As you are well aware by now, the Patient Protection and Affordable Care Act  (PPACA) that became law in 2010 requires you to provide preventive care visits consistent with Bright Futures Guidelines for children at no cost to the patient or family, including well child exams, vision and hearing screening, immunizations, and obesity counseling, among other services. 

These visits are not subject to a copay, coinsurance or deductible, so patients who schedule them come to your practice expecting to leave without paying any money out of their pockets. However, not every preventive visit remains preventive—as any pediatrician can tell you, problems can be found during the visit, or other significant issues could be addressed by the parent. When this happens and your wellness visit is accompanied by a charge for a problem-oriented visit, you could face confusion from patients, who will then be subject to copays and deductibles when they’ve received more than just screening care.

Check This Example

Suppose a six year-old patient presents for a wellness visit, but the patient’s mother is concerned that the child also has been complaining about ear pain after swimming lessons. The pediatrician examines the patient’s ear and diagnoses her with swimmer’s ear. He prescribes ear drops to treat the otitis externa.

In this case, the patient presented for a “free” physical but you discovered a significant problem that was separately evaluated during the visit. You’ll report the preventive medicine code (for instance, 99393, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/ diagnostic procedures, established patient; late childhood [age 5 through 11 years]) with the diagnosis code V20.2 (Routine infant or child health check). This requires that all of the elements of the preventive visit are met, even though the child is ill.

In addition, you’ll report the appropriate E/M code (such as 99212-25) linked to 380.12 (Acute Swimmer’s ear). 

This visit will prompt a copay due to the 99212 charge. Therein lies the issue that your front desk personnel will have if the parent balks at the payment that is now due at the visit. If you face such issues with your patients, consider the following three tips to ensure that these patients still leave your practice satisfied, despite having to pay for a non-wellness service.

1. Explain Your Contractual Agreement. Tell the patient’s family that you have a contractual agreement with the insurer that requires you to report problem/sick visits when you perform them. Explain that if they have the issue addressed while they’re already at your office, you are legally required to submit the claim to their insurer for the service. 

2. Consider An Educational Brochure. Many practices have been able to quell this issue by creating a short one-page fact sheet about billing that explains the difference between a preventive medicine visit (such as a well child check and a vaccine) and a problem visit. The sheet can explain what each visit costs, what the PPACA covers (and what it doesn’t), and which visits are exempt from copays and deductibles. 

Having such an educational sheet not only explains the billing process to the patient, but it also shows that you aren’t singling that patient out for a carved-out payment along with the wellness visit. Particularly in cases when patients have high copays and deductibles, they can sometimes think you are targeting them with a “surprise” problem-focused service, when in reality the brochure can explain that this is fairly common and can show them what their rights are.

3. Offer to Have the Patient Return Later. In cases when the patient is getting a no-cost service and you foresee also billing a problem visit during the same session, explain that the problem-focused visit will prompt a copay/deductible so the parent knows about it up-front. In cases like a bead stuck in the patient’s nose or something else that’s urgent, the option of coming back another day might be impossible. However, if the parent wants to discuss the patient’s ADHD, you should offer for them to come back another time because that problem-focused discussion will turn the wellness visit from a “free” encounter to a paying visit. 

Of course, when the parent returns, they will still be subject to the deductible and copay, but at least they’ll know about it and be able to make the decision of whether they want to pay it now or pay it later.