Pediatric Coding Alert

Question: We are a large multispecialty group. Some coders who file Medicare claims suggest that we always code based on the Correct Coding Initiative (CCI) edits. Since we report claims to private payers only, we have been following CPT guidelines. Who is right?

Missouri Subscriber

Answer: Before deciding who is "right," consider a few factors.

1. The hierarchy. The AMA creates current procedural terminology (CPT) guidelines, which appear in the CPT manual. Medicare implements these guidelines in the form of quarterly CCI edits. CCI's code pairs can affect how you use CPT codes and can create coding conflicts. The CCI edits do not necessarily reflect AMA's CPT rules.

You would have to follow Medicare rules if you were coding for a Medicare carrier as your peers who bill beneficiary services do. But because pediatric practices don't bill Medicare, they do not have to adhere to CMS' stricter guidelines.

Think of it another way. ICD-9 guidelines have instructions that private payers sometimes do not follow. For instance, when sequencing codes for a follow-up otitis media encounter during which the provider no longer finds OM, the optimal ICD-9 answer is V71.89 (Unfound condition). But most payers also want you to list the condition that is no longer present -- the OM, such as 381.1x. Here, although you should follow ICD-9 guidelines, you must adhere to the method the payer requires.

2. Payment. Some consultants recommend applying Medicare's stricter guidelines to all payers for compliance reasons. Other experts, however, suggest coding per insurer to obtain the maximum ethically allowed pay.