Pediatric Coding Alert

How can you boost that low-level to a higher-level E/M visit and recoup more than an extra $15 (99212 to 99213), $29 (99213 to 99214) or $38 (99214 to 99215) per visit? Use time as a factor when your pediatrician spends the majority of the encounter on counseling.

As easy as time-based billing may sound, numerous pediatricians fail to include full documentation of the encounter. Reviewing records or discussing risk-factor reduction with family members can significantly boost the level of E/M service, says Gail Benjamin, CPC, accounts receivable technical adviser for Apex Practice Management in Oakland City, Okla. But, if the pediatrician omits the counseling from her notes, the documentation will not support the higher-level code, she says.

Extensive Areas Qualify as Counseling

CPT allows billing based on time when the physician spends 50 percent or more of the visit in counseling. Many pediatricians are unaware of how many areas count as counseling time. Topics that count as counseling include, according to CPT:
  diagnostic results, impressions and/or recommended  diagnostic studies
  prognosis
  risks and benefits of management (treatment) options
  instructions for management (treatment) and/or follow-up
  importance of compliance with chosen management options
  risk-factor reduction
  patient and family education.

Parent Discussions Count Toward Time

You may count face-to-face discussions with a patient and/or family member as counseling time. Our pediatricians spend a lot of time with the patient and the parents but rarely take the parent time into consideration when coding, says Kim Spinosi, CPC, coder at Physician Health Alliance Inc. in Scranton, Pa. They perform a great deal of counseling and risk prevention without taking credit or documenting the encounter.

Many pediatricians dont realize that parent discussions count as part of the E/M service. But face-to-face time with the patient and/or family counts in determining code selection, says Barbara Cobuzzi, MBA, CPC, CPC-H, president of Cash Flow Solutions, a medical billing firm in Lakewood, N.J Encourage your pediatrician to document total time, time of the counseling, and what the physician discussed with the parents, Cobuzzi says.
Capture All Counseling Aspects

Pediatricians frequently forget to put all face-to-face counseling topics in their notes or fail to elaborate on what they did, Benjamin says. They especially overlook requesting and reading old records and discussing these with family members, she says. If a pediatrician fails to document the extent of the counseling, she has to forfeit the higher reimbursement.

Time Example: Prior to examining a 6-year-old girl who has a sore throat and headache (99212, physicians typically spend 10 minutes), a pediatrician requests old patient records for the child. The problem-focused history and examination take only 10 minutes. But the pediatrician spends an additional 15 minutes face-to-face discussing with the mother the childs frequent illnesses, her prior medical records, and possible treatments.

Based on the history and exam components, the visit qualifies only for a level-two office visit. But if the pediatrician had included the counseling information in her documentation, she could justify a level-four office visit (99214). In this case, incomplete counseling documentation will sacrifice more than $44 for the visit, based on the National Physician Fee Schedule.

In fact, showing the pediatrician the money is Spinosis number-one suggestion for combating undercoding. After an audit, show the pediatrician where she could have gained additional reimbursement, Spinosi says. Money-based education often makes a difference.