Pediatric Coding Alert

Question: Most of our patients know that under the Affordable Care Act, patients get free wellness visits with no copay or deductible. But sometimes during preventive visits, the pediatrician will find something wrong and then we bill a sick visit code, which does prompt a copay. Then when the patient checks out, the parents get upset because they thought they were there for a free visit. Is there a way around this?

Codify Subscriber

Answer: There isn’t a way around having to pay a copay if the pediatrician finds a problem and you have to bill a separate sick visit, but there are ways to explain it to the parents to hopefully ease their confusion.

First, explain your contractual agreement with the insurer. Tell the patient’s family that you have a contract with the payer that requires to report all services rendered to the patient on a given date. Explain that if they have the issue addressed while they’re already at your office, you are legally required to submit the claim to their insurer for the service. 

In cases when the patient is getting a no-cost service and you foresee also billing a problem visit during the same session, explain that the problem-focused visit may cause a copay/deductible to be due so the parent knows about it up-front. In cases like an allergic reaction or something else that’s urgent, the option of coming back another day might be impossible. However, if the parent wants to discuss the patient’s ADHD, you should offer for them to come back another time because that problem-focused discussion will turn the wellness visit from a “free” encounter to a paying visit. 

Of course, when the parent returns, they will still be subject to the deductible and copay, but at least they’ll know about it and be able to make the decision of whether they want to pay it now or pay it later.

Many practices have been able to quell this issue by creating a short one-page fact sheet about billing that explains the difference between a preventive medicine visit (such as a well child check and a vaccine) and a problem visit. The sheet can explain what each visit costs, what the Affordable Care Act covers (and what it doesn’t), and which visits are exempt from copays and deductibles.

Having such an educational sheet not only explains the billing process to the patient, but it also shows that you aren’t singling that patient out for a carved-out payment along with the wellness visit. Particularly in cases when patients have high copays and deductibles, they can sometimes think you are targeting them with a “surprise” problem-focused service, when in reality the brochure can explain that this is fairly common and can show them what their rights are.