Pediatric Coding Alert

It happens often enough in pediatrics: A child comes in for a well visit, and turns out to be sick. The pediatrician performs the well visit, and thenin additiontreats the problem. But in order to get paid for both preventive care services (99381-99385, 99391-99395) and an office visit, you need to put a modifier -25 on the office-visit code. This tells the insurance company that yes, you are billing for two E/M services on the same day, but the reason is that you provided two separate services.

This modifier is supposed to be CPTs built-in mechanism for ensuring that a physician will get paid for the extra work involved in seeing a patient twice on the same day, without having the patient return for a separate visit at another time. Unfortunately, insurance companies dont always recognize modifiers. They see the two E/M codes, and either deny one and pay the other, or bundle them into one code and pay their contractually agreed upon fee for that one code.

Appeal, Appeal, Appeal

We talked to one office manager who, after a year of persistence, has succeeded in getting most modifier -25 claims paid. We appeal them left and right, and thats how weve succeeded, says Marion Hayes, office manager for Shapiro and Bernstein, a three-pediatrician, one-nurse practitioner practice in Silver Spring, MD.

Most pediatricians make the mistake of giving up after the first denial, says Hayes. Or they see a pattern of denials and throw up their hands in dismay, saying its too much trouble. The insurance companies know all about the modifier -25, Hayes comments. If you say nothing, its to their advantage. But if you fight it, then you have a chance.

Hayes began her modifier -25 battle with the insurance companies a year ago, when the practice first started using it. We could have given up then, because everything was getting rejected, Hayes reports. But she persisted. First of all, she noticed that the EOBs came back one of two ways: either denied or bundled.

If its denied, that means we have to educate the insurance company about the meaning of the modifier -25, she says. We tell them to read the CPT book, she states. We have a photocopy of CPT Codes , and we send it to them, she adds. And we talk to them about it.

Another problem is bundling. The insurance company takes the preventive-medicine services code (like 99393) and adds the office-visit code (such as 99313) to it. For example, the pediatricians claim is for $78 for the preventive-medicine services and $50 for the office visit. The insurance company adds up the two figures, leaves only the 99393, with $128 as charges billed, but reimburses only the contractually agreed upon fee for the 99393, which may be only $60. Again, some modifier -25 education is in order. And Hayes does that by getting on the phone with the insurance companyeach and every time.

The key to Hayes success, she believes, is the fact that she doesnt talk to whoever answers the phone. Instead, she makes sure she is talking to a supervisor. We appeal these if rejected, but we have to start with a supervisor, the office manager stresses.

An appeal doesnt have to mean complicated paperwork. In fact, Hayes refuses to resubmit claims. I tell them it was their mistake, and they have to go back and fix it, she says. They have to process it againI dont resubmit.

Also, its interesting that insurance companies have never asked for doctors notes before they pay these claims, says Hayes. The modifier education aloneas well as the realization that they are dealing with someone who isnt going to give upmay be working. This is about delaying payment, says Hayes.

Not every single claim comes through, Hayes notes. Even now, a year later, she still has to educate managed care companies. But I would not stop doing it, she says. Pediatricians are getting raked over the coals by these companies, and we need to do something to stop it.

By the way, Hayes sends all modifier -25 rejections to the local medical society, which is getting lobbyists involved in this battle. My gut feeling is that so many physicians are finally filing the modifier -25 now, that insurance companies cant pretend it doesnt exist, Hayes says.

You Have to Use It

Before you can win a battle against insurance companies, you have to actually use the modifier. Asked how Hayes convinced her pediatricians to use it, she laughs. It took us almost two years, she reports. First we told them they can do it. Then we showed them the CPT book and they read that they can do it. Then we brought in a coding consultant who told them they can do it. Finally, one pediatrician started using the modifier, quite tentatively at first. He only would use it occasionally and, unfortunately, it seemed as if every time he used it the patient was in a capitated plan, so it didnt matter, says Hayes, who has a sense of humor to match her fighting spirit. Then more and more they all started using it. Now, Hayes shows them the EOBs. When they see that were getting paid for it, that makes them feel a lot better about using the modifier, she notes.