Pediatric Coding Alert

Question: I contacted my insurer and asked how they prefer me to submit codes for a particular ear procedure, and the representative said “We can’t give you coding advice.” However, because we are in a resort town, we see patients from various states and we have no way of knowing how their insurer prefers the coding to be for different procedures. How can we get this information?

North Carolina Subscriber

Answer: You are correct that most insurers vary in how they want different procedures reported, but you may have better success in finding out their preferences if you tweak the way you ask the question.

For instance, rather than calling the payer and asking “How should I code cerumen removal,” ask the insurer’s reps, “Where can I find a copy of your cerumen removal policy?” It’s a subtle difference, but it changes the onus on the rep from telling you how to code your service (without having seen your documentation) to simply referring you to the insurer’s policy and asking you to interpret it.

This is helpful in situations where you’re looking for applicable diagnosis codes or frequency guidelines, since most payers list those in their policies. Often, you can bypass calling the insurance representative by simply searching your insurer’s website for its policies, but if the website doesn’t turn up any applicable information, then you should make the call and ask for the policy in writing.

Warning: Remember that you should never select a code simply because the insurer’s policy says that it’s payable—always base your coding on the documentation itself. However, medical policies are helpful in determining whether your notes have what it takes to collect on the claims so you’ll know beforehand whether a patient’s diagnosis is payable or whether you should have the parent sign an Advance Beneficiary Notice (ABN) in case of possible denial.