Pediatric Coding Alert

Marc A. Tanenbaum, MD, of Atlanta, GA writes, We contract with over 40 managed care companies and have found that uniformly they all refuse to pay for both services (routine preventive health visits and problem-oriented care) even when properly modified. They will pay for one or the other of the two services, but not both, and usually the lesser of the two. Do you have any suggestions (other than having us refuse to provide both services to our patients, which would certainly not be appreciated by them)?

This is an overwhelming problem for pediatricians: a child comes in for a well-child visit, you discover an ear infection, but you can only bill for the well-child visit or an office visit. Dean Leanch, reimbursement analyst at Practice Solutions, Inc., a firm which does billing for pediatricians and internists, has the following advice.

The ultimate answer to Tanenbaums question is not to give up, says Leanch. Have your billing manager or office manager take it up with the managed care organization, refer them to the appropriate CPT language (printed below), and let them know that you are going to keep demanding that they recognize these codes. The definition of an HMO is they want to pay the physician less, offer premiums for less, and make more money, Leanch believes, adding that that definition does not include coding know-how.

Take Aetna/U.S. Healthcare, says Leanch. They do not recognize modifiers. Every time he bills for a well-visit and an office visit, the payer puts them together, he explains. Leanch is dealing with this by meeting with representatives from the managed care organization. I asked them, how can an ear infection be part of a physical? the analyst relates.

It sounds like the insurance company is telling me that the patient has to come back the next day, either for the well-visit or for the ear infection, Leanch relates. Thats ridiculous. I cant tell a physician to bring your patient back the next day -- and the parents would never stand for it.

So what does the reimbursement analyst tell his pediatricians to do if they have to treat a problem during a well-visit? I give my physicians three choices, he says.

1. Bill the physical with an office visit with the -25 modifier. Thats my first choice. (Tip: Remember, if you utilize the 25 modifier put it on the office visit, with the diagnosis code (382.00 for otitis media, for example). Then put the appropriate diagnosis code (V20.2 ) for the well-visit.)

2. Bill the physical with any ancillary services they provide, such as a urinalysis.

3. Bill a higher level office visit, instead of the well-visit. There are some problems with the third choice, Leanch concedes. The main one is that HMOs generally pay 100 percent of a well-visit, but considerably less for an office visit. So youre going to lose out on money if you take that route, he says. (Note: Also, HMOs track well-visits. If you change a physical to an office visit, the HMO may come back at you and ask why you havent been doing physicals at the scheduled times. They might even say you are filing fraudulent claims.)

Diagnosis Codes

Its very important that you put the diagnosis in the right place, notes Leanch. Ive dealt with some managed care organizations that are very good about processing these claims, as long as youve filed them correctly. If a child comes in for a well-visit, and the pediatrician finds otitis media, you cannot submit otitis media as the primary problem, stresses Leanch. A good company will deny that claim, and rightly so, he says. When you report a presenting problem with a physical, they dont match, he says.

(Note: There are insurance companies that pay for both services, if the modifier is correctly used. In North Carolina, Blue Cross/Blue Shield -- both the capitated and the non-capitated plans -- pay, says Leanch. So do other smaller plans.)

Modifier -25 -- CPT 98: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patients condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier -25 to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.