Pediatric Coding Alert

Preoperative physicals are problematic for pediatricians. This is because children have regular well-visits anyway, something that managed care organizations usually require. But these same managed care organizations refuse to pay for more than a certain number of physicals, one every year or every two years, for example. Accordingly, how can you bill for an additional well-visit for a pre-op physical, using correct coding and still get paid? The best way, if you are concerned about reimbursement, may well be to use a sick-visit code, according to two office managers we discussed the problem with.

Also getting paid is the point, says Patricia Vogel, office manager for Adirondack Pediatrics, a five-pediatrician, two-nurse practitioner practice in Glens Falls, NY. The question is key, because the fact is that insurance companies make it very difficult to get paid for these visits. Any way they can get out of paying, they will,she adds, with a good-natured laugh. But, we are using the regular sick-visit codes and not having a problem.

If the surgery is going to be for ear tubes, one of the most common reasons for pre-op physicals, the code would probably be a 99213, says Vogel. If, however, its for something like open-heart surgery, the pre-op physical would be coded a 99214.

Vogel uses the preoperative respiratory examination diagnosis code: V72.82 .

Shortened Physicals

Ann Corlew, office manager for Pediatric Care, Inc., a solo practice in Hendersonville, TN, takes a similar approach. We cant use preventive services if the patient has already had the yearly physical, she says. But, if the child has had a physical within the last six months, the pediatrician will do a review of systems, just as she would for a complete physical. However, she wont do all of the other procedures that are part of a physical, such as hearing and vision tests, says Corlew. She checks the heart, lungs, and abdomen, the office manager notes.

Like Vogel, Corlew uses a regular sick-visit code for these physicalsusually, 99212, 99213, or 99214. The pre-op physicals rarely take as long as regular physicals, she
adds.

Virtually every pre-op physical done at Pediatric Care since Corlew became office manager four years ago has been for dental procedures. A lot of pediatric patients need to be anesthetized before dental procedures, notes Corlew. So, they need pre-op physicals. Surgeons themselves do their own pre-op physicals, or have them done at the hospital, says Corlew. But we do a lot of pre-dental physicals.

Corlew doesnt use the clearance diagnosis codes for these physicals. Instead, she uses the diagnosis code for the condition that coincides with the procedure that is being donedental caries (521.0), for example.

Consults

What about consultation codes? We tried that, says Vogel. We always end up with an argument from the insurance company, because they say we cant do a consult on our own patient. The fact that the surgeon has requested the physical apparently carries little weight with these carriers.

Regardless of what insurance companies say, preoperative physicals are clearly consultation exams. The CPT descriptions for consultations do not describe the patient as new or established, and this issue is not relevant. Indeed, you can do a consultation on your own patient.

In the real world, each practice must decide what is worth fighting for. A consultation may well be worth such a fight. According to Healthcare Consultants of America 1998 Physicians Fee and Coding Guide, the office consultation codes reimburse well. The ranges are:

Code	Price range
99241	$88 to $109
99242	$118 to $146
99243	$145 to $182 ,
99244	$812 to $227 
99245	$244 to $308.

And, remember that a higher level code may be appropriate for pediatric preoperative consultation. The pediatrician is being asked to evaluate the patients ability to tolerate anesthesia and survive surgery. Often, the patient has never been exposed to anesthetic agents, so there is no indication for or against an allergic reaction. This makes for a higher level of medical decision making.

Note: The problem is that there is no specific procedure code for such a physical, beyond the preventive services codes (99381-99385 for new patients, 99391-99395 for established patients). And as Vogel and Corlew know only too well, insurance companies will not pay for physicals if they are done more frequently than their pre-set schedules. But, this fact is besides the point. The physicals are not being done for the purpose of preventive medicine; they are done to make sure a patient can undergo anesthesia. Since there is no procedure code for such a physical, pediatricians are left to their own devices in figuring out how to bill this visit.