Pediatric Coding Alert

When patterns review software first threatened to cut reimbursements for pediatricians in Florida, there was panic. This software compared among other things the diagnoses on individual pediatricians claim forms with those of other physicians. If the program detected, for example, too many diagnoses of otitis media, the claims were downcoded from 99213 to CPT 99212 . The software also threw out all but the most specific diagnoses: If the diagnosis was abdominal pain (789.0x), the claim was denied for lack of specificity.

They [the carriers] never told us they were going to do this, says Edward N. Zissman, MD, FAAP, a CPT regional coding trainer for the American Academy of Pediatrics (AAP), and president of the AAPs Florida chapter. They sent out a note saying they would adjust claims for the severity of the patients illness. What they did was downcode 99215s, 99214s and 99213s. To appeal, a pediatrician had to submit a special form along with all office records regarding the claim. If the appeal referred to a broad problem, such as the plan not covering the nonspecific diagnosis of abdominal pain, the pediatrician was also required to submit two journal articles supporting the diagnosis.

It was a delaying tactic, keeping us from getting paid for 90 or 120 days, Zissman says. We told them it was unacceptable, and that we would take it to the AAP.

Florida pediatricians eventually prevailed, and carriers ceased using the pattern review software. For those pediatricians who may face a similar predicament, Zissman recommends the following:

Talk to patients: We told parents that it would be hard for us to continue to see patients in that plan, because the plan was refusing to pay us for the work we do, says Zissman. Parents, who along with their children have formed bonds with the pediatric practice, angrily take this information back to their employers. The employers complain to the plan. And the plan starts to worry about losing big accounts.

Threaten not to see the plans patients: One very large pediatric group in Florida did this, Zissman recounts. It was effective but you do need to be a large group to have this kind of influence.

Note: Because of antitrust regulations, you cannot band together with other groups and make this threat, Zissman warns, but you can do it as one practice.

Terminate the contract: Another very large group 400-plus physicians, including pediatricians quit the plan. This left a big coverage gap in the area, creating a major problem for the plan.

Write everybody: The state insurance commissioner, local legislators and the governor received copies of the letters Zissman sent to the plans medical director.

Zissman feels perseverance [...]