Pediatric Coding Alert

Look for comprehensive payment information for each service.

Last month we looked at two ways your practice can bring in more income to upgrade office equipment, adjust care programs, and improve patient outcomes. This month we explore two more revenue-increasing opportunities suggested in the 2019 webinar titled, “7 Pediatric Services That Will Save Your Patients… And Your Practice,” as presented by Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC.

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.

3. Determine Payment for Developmental and Behavioral Screenings

Developmental and behavioral screenings are often overlooked from a coding and billing perspective. However, “they are a crucial service pediatricians provide to children. They are a standard of care,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.

If you’re working with family members, friends, and school nurses and documenting information, make sure you’re billing for the scoring and interpretation of those questionnaires. “You can bill for all of them,” explained Blanchard. “If you’ve got forms from several teachers, both parents, a grandparent, etc., you can bill every one of those independently as a unit. Don’t overlook the opportunities with that,” she continued.

Patient benefit: Identifying attention deficit hyperactivity disorder (ADHD), teen depression, and even postnatal depression in new mothers early on is ideal if you want to maximize the treatment benefit. Early intervention is the best way to prevent unnecessary suffering, said Blanchard.

Financial details: In 2019, a developmental screening paid PCC clients an average of $11.00. An emotional/behavioral screen paid an average of $5.70. A caregiver-focused health/risk assessment paid an average of $5.40. Just for those three, not even taking into account the possibility of patient-focused health/risk assessments, the potential was for nearly $10,000 in additional payments per clinician.

Here’s how it breaks down:

• 30 total visits per clinician per year, according to American Academy of Pediatrics (AAP) recommendations
• 9 out of 30 visits include the developmental screen, which is 536 visits ($5,896.00)
• 7 out of 30 visits include the emotional/behavioral screen, which is 417 visits ($2,376.90)
• 4 out of 30 visits include a caregiver health/risk assessment, which is 238 visits (1,285.20)
• Combined total is $9,558.10 per clinician per year

Coding:

• 96110 (Developmental screening (eg, developmental milestone survey, speech and language delay screen) … )
• 96127 (Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale…)
• 96160 (Administration of patient-focused health risk assessment instrument…)
• 96161 (Administration of caregiver-focused health risk assessment instrument…)

Challenges: The important thing about using these codes is that the tests have got to be standardized. “They’ve got to be peer-reviewed with a standard scoring system. So, make sure that the tools you’re using qualify,” warned Blanchard. The Ages & Stages Questionnaire (ASQ) is a good example, she says (https://agesandstages.com/about-asq/).

4. Monetize After-Hours Care

Convenience is worth a lot to some people, and after-hours care is no exception. The one caveat to this service is that it requires the practice first spend money on staffing, and that the staff spend more time at the office. However, “appropriate use of the after-hours codes can not only get you paid for your work; it tells the payers that you are available to your patients,” says Hart.

Patient benefit: Often, the only after-hours care option for patients is the emergency room (ER). Therefore, providing after-hours services prevents a trip to the ER and offers the patient a familiar, convenient place to receive care outside of normal business hours. “They’ll likely get more care from you than from someone who doesn’t know them and is already overworked,” said Blanchard.

Financial details: Payments for office visits occurring on regularly scheduled evening, weekend, or holiday office hours averaged $7.95 per visit. If you factor in adding just that one additional service to your practice, your practice could bring in almost $2,000 per clinician per year.

Here’s how it breaks down:

• 10 visits per month for evening, weekend, and holiday hours, which is 250 per year ($1,987.50)

Coding:

• 99050 (Services provided in the office at times other than regularly scheduled office hours)
• 99051 (Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours…)
• 99056 (Service(s) typically provided in the office, provided out of the office at request of patient…)
• 99058 (Service(s) provided on an emergency basis in the office, which disrupts other scheduled office services…)
• 99060 (Service(s) provided on an emergency basis, out of the office…)

Challenges: If you currently offer these services, but aren’t utilizing the after-hours codes, it’s a good idea to let the patients know you’ll soon start billing for these services. “Some of them value that convenience enough that they’ll accept this as a tradeoff,” said Blanchard. Additionally, the patient out-of-pocket would likely be much greater at an urgent care or ER facility, which can be a helpful perspective to point out to parents. Remember that patients aren’t the only ones who pay more for ER care.

While more and more carriers are paying for these services, be aware also that some will push back about these codes with their own interpretations of what the codes mean. Answering them with the specific language as written in the CPT^® manual should be enough to make your case. “They’re beholden to the same CPT^® that you are. Don’t assume they have some other reference that you don’t know about,” assured Blanchard.

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 and reveal what the total revenue increase could be for all the services combined.