Pediatric Coding Alert

Question: One insurance company downcodes all of our CPT 99213 s (established patient office or other outpatient visit) to 99212s. They say the decision is based on the diagnosis alone. How can I respond to this?

New York Subscriber

Answer: This problem started with 99214s, which, unless submitted with supporting documentation, were downgraded to 99213s. Then, some companies started doing it to 99213s.
 
Recognize that CPT coding represents documented work done, not the diagnosis for which the work is furnished. But, more complicated diagnoses may more clearly support higher coding levels for more work done.
 
Sometimes the best route is to use more than one diagnosis code. Pediatricians have to understand that the person looking at these claims may not be able to understand your documentation. This person does, however, understand quantity.
 
Don't make up diagnoses. Instead, look at your notes and convert the symptoms to diagnosis codes. For example, a child with otitis media (381-382) may well also have a fever (780.6) and vomiting (787.03) caused by gastritis. Be sure to put the primary diagnosis first. Only the physician can determine the primary diagnosis; if this isn't clear from notes, the coder must ask. When you code more than a problem-focused visit, multiple diagnoses can provide immediate evidence that your documentation will support the higher-level E/M code.
 
Also, if possible, avoid an "unspecified" or "other" diagnosis code in the primary position. If this is the primary diagnosis, so be it. But insurance companies prefer a more specific diagnosis.
 
Don't forget the signs and symptoms section (780-789) of ICD-9 in selecting diagnosis codes as well.