Pediatric Coding Alert

These rules for billing levels of service may actually increase your reimbursement,and put you ahead of the game with private payers

The CPT documentation guidelines for E/M services are created for Medicare. Theres no dispute about this. But does this mean pediatricians, who do very little work with Medicare, can ignore these guidelines? No, our sources say. Thats because Medicare is bellwether when it comes to coding. Where Medicare goes, Medicaid and the private payers follow. If you are using the guidelines now, you will be prepared for whats coming. And if you do useand stick tothe guidelines, you can give commercial carriers a good argument if they refuse to recognize Medicare-accepted coding, like using modifier -25 when filing for a well visit and a sick visit done on the same day. You can ask your payers, How dare you go against HCFA? referring to the Health Care Financing Administration, which in addition to administering Medicare also writes CPT and the documentation guidelines with the American Medical Association.

Pediatricians who are in large multi-specialty practices or are affiliated with university hospitals are the most likely to be required to use the documentation guidelines. This is because the rest of the hospital departments have to use them in order to pass Medicare audits. But, even in these cases, pediatricians often resent having to do the documentation.

Our current auditing system is produced by the Medicare organization which has very little concern regarding pediatric care, writes a subscribing pediatrician who is with Hannibal Clinic, a multi-specialty practice based in Hannibal, MO. The clinic conducts internal chart audits throughout the year to evaluate the documentation, to make sure that it supports the level of service being charged. By using this Medicare system to audit our pediatric charts, we are attempting to impose rules and regulations which may be appropriate in the care of an adult, but are very inappropriate in the care of a child, the pediatrician concludes.

Unfortunately, the Medicare guidelines are the only documentation guidelines that exist, and they are to be used across all specialties, including pediatrics. The American Academy of Pediatrics (AAP) does have input into these guidelines, and works hard to try to get pediatric interests recognized by HCFA.

Pediatricians have a vested interest in using the documentation guidelines, because regulations that are implemented by Medicare are usually adopted by Medicaid and private payers, says Bela Agrawal, senior health policy analyst with the AAP. But its true that the federal government [HCFA] doesnt have a say over what the private payers and the state Medicaid programs do. And, as many pediatricians have noticed, commercial payers have a way of adopting some of the Medicare rules, but not all. But even if theyre only going to adopt some, its important for us to react, says Agrawal.

Benefits of 1997 Guidelines

However, not every pediatric practice is opposed to using the guidelines. We talked to one practice that is using the 1997 version and has had a good experience as a result.

We have been able to use more fourth-level codes because of using the 1997 guidelines, says Mary Alice Baldwin, CPC, administrator of Columbia Pediatric Clinic, a nine-pediatrician, two PNP practice in Columbia, TN. When they started using the guidelines, the doctors realized that they had been previously undercoding, she says. Pediatricians are inclined to undercode anyway. But so much of what the pediatrician does is multi-system, Baldwin notes. Many pediatricians automatically assume that they are doing routine sick visits. But they never just check an ear. They listen to respiratory, they check the bellythey do a lot that qualifies for a higher code, she explains.

Another benefit of using the documentation guidelines consistently is that if managed care payers determine, for example, that you bill too many 99214s, you can invite them to examine your documentation, notes Baldwin. And there is always Medicaid.

Anyone who accepts Medicaid should be using these guidelines, she says. Her practice went through a random audit by Medicaid, and the use of the guidelines helped immensely. I was very glad to have the consistency of documentation, she says. Using the guidelines made us above reproach.

Not as Hard as it Seems

Was it difficult for the providers to adapt to the documentation requirements? It was much less painful than we had expected, reports Baldwin. Its really not any different from what we were doing anyway. Training was done during a meeting between Baldwin and the providers. I took them through the bullets, and we did some case studies. The pediatricians listened to a tape I brought back from a conference, she relates. Also, there were some inservices conducted locally which some of the pediatricians attended. We all sat around and discussed it and agreed that we would use the guidelines.

Finally, Baldwin urges pediatricians to pay attention to Medicare regulations. I dont discount something just because it says Medicare, she says. And I dont feel that the specialty of pediatrics is exempted. The fact is that these guidelines are eventually going to be required by all providers, including pediatricians, Baldwin believes. Its in our best interest to use them, she says. And its inevitable that they will be required as care gets more standardized.

Note: Watch for stories on changes to the E/M guidelines in future issues of PCA.