Pediatric Coding Alert

And learn how to overcome payment challenges.

Periodically assessing how the practice is doing can have a huge impact on efficiency as well as your bottom line. In her 2019 webinar titled, “7 Pediatric Services That Will Save Your Patients… And Your Practice,” Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC, explains how your patients and practice can better maximize your services rendered. “This isn’t about lining pockets,” said Blanchard. “You want to turn that money around to improve patient outcomes, improve care programs, or replace old equipment.”

Follow us through this three-part series as we examine each of those services to show you how and why your patients and practice could benefit with just a few adjustments.

Note: Most of these tips function under the following baseline assumptions:

• A single clinician with a full-time workload equates to working four days a week, which means approximately 25 patients a day for approximately 50 weeks per year, which is roughly 5,000 visits per year.
• Practices have quick access to their sick-visit-to-well-visit ratio (well care pays differently than sick care does).

Clearly, not all services discussed occur daily. Some services are seasonal, some are weekly, and so on. Additionally, because new patients are only new once during a three-year period, these calculations are made with only established patients in mind.

1. Consider Fluoride Varnish Applications

The American Academy of Pediatrics (AAP) and the United States Preventive Services Task Force (USPSTF) recommend fluoride varnish application every three to six months once teeth are present through age 5.

Patient benefit: Poor oral health has been attributed to “everything from failure to thrive to reducing self-esteem to difficulty sleeping,” said Blanchard. The mouth is teeming with bacteria, most of which are harmless, but because the mouth is the door to the entire digestive and respirator tracts, good oral health can contribute to a host of other more serious conditions (Source: https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475)

Financial details:

The average reimbursement for this service across geographies and payers is just under $20 per application, and some payers pay up to $30, Blanchard explained. “This is the holy grail of preventive services. It’s a good preventive service that pays well,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant. “It’s a preventive service that Medicaid programs pay as a rule. In other words, it’s an important service for the underserved that pays without much hassle,” Hart elaborates.

Here’s how it breaks down:

• Costs under $5 per dose
• Patients under 5, every three to six months = approxi­mately 533 out of 5,000 visits are eligible
• 533 x $19.14 (average payment) = $10,201.62 per clinician per year

To learn more about ways to access information about low-cost supplies and service training, go to www.aap.org/ en/community/aap-sections/administration-and-practice-management/.

Coding: How these services will be coded will likely depend on the payer. You’ll likely use one of the following:

• 99429 (Unlisted preventive medicine service)
• 99188 (Application of topical fluoride varnish by a physician or other qualified health care professional)
• D0120 (Periodic oral evaluation - established patient)
• D0145 (Oral evaluation for a patient under three years of age and counseling with primary caregiver)
• D9999 (Unspecified adjunctive procedure, by report)

Challenges: “The number one argument from parents is that not all carriers cover this service,” said Blanchard. Yet on the flip side, this is a preventive service, “so if they don’t have dental coverage, you are likely doing them a favor by saving them money in the long run,” she continued. Presenting parents with the distinct possibility that they’re avoiding a larger financial burden in the future can be helpful. As with anything that is known to potentially require out-of-pocket payment, it’s always best to offer that information ahead of time.

2. Resist the Urge to Hold Off on Billing Hearing and Vision Screenings

The AAP recommends a variety of screenings and assessments be performed at well-child visits from infancy through adolescence. Hearing and vision screenings are among those recommendations. Most, if not all, practices perform these screenings because it’s best practice. However, many are not charging for them.

Patient benefit: Early intervention is vital to giving children the maximum treatment benefit. “Educate parents on the importance of these screenings, and the types of conditions they can catch and the suffering that is preventable,” said Blanchard.

Financial details: A pure tone hearing test pays at an average of $11.60. The screening test of visual acuity pays at an average of $2.73.

Here’s how it breaks down:

• 30 total visits per clinician per year, according to AAP recommendations
• 19 out of those 30 visits recommend the hearing test, which is 1,131 visits ($13,119.60)
• Eight out of 30 visits recommend the vision test, which equals 476 visits ($1,299.48)
• Combined total is $14,411.08 per clinician per year

Coding: How these services will be coded depends on which screenings you’re performing. For example, you might use one or more of the following:

• 92511 (Screening test, pure tone, air only)
• 92552 (Pure tone audiometry (threshold); air only)
• 92558 (Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis)
• 99173 (Screening test of visual acuity, quantitative, bilateral)
• 99174 (Instrument-based ocular screening (eg, photoscreening, automated-refraction), bilateral; with remote analysis and report)

Challenges: Some payers claim they won’t pay for these services because they’re bundled with the well-child visit, so it’s best to check your contract for any agreements that override CPT^® guidelines. If there isn’t language about bundling, appeal the denial, advises Blanchard. “E/M [evaluation and management] services of which well-care codes are part, are distinct from screenings. CPT^® language carves out screenings. If your carriers are bundling them without a previous arrangement, they’re in violation of your contract,” she continued.

For access to the full webinar, go to https://info.pcc.com/7-pediatric-services-that-will-save-your-patients-and-your-practice-lp

Note: In next month’s issue, we’ll examine more services to help you maximize revenue for services you’re probably already performing.