Pediatric Coding Alert

Question: When we report a level-three E/M service, one of our insurance companies always down-codes it to a level-two service. According to the insurance company, our diagnosis codes don't support the higher-level service. What are we doing wrong?
     
New Jersey Subscriber

Answer: You're not the only one whose insurance company is downcoding their E/M services; luckily, there is a way to combat this trend.
 
To justify to the payer the extra work your pediatrician performed, you may need to report more than one diagnosis code.
 
Don't list diagnosis codes that don't apply to the patient; rather, be sure you are converting all of the patient's symptoms into ICD9 Codes that you can link to the E/M code. Report the primary diagnosis, followed by diagnosis codes for any related symptoms the patient had.
 
For instance, an extrinsic asthma patient presents with difficulty breathing and a fever. The pediatrician performs a history, examination and medical decision-making and administers an inhalation treatment for the asthma. Link the diagnosis for fever (780.6) to the E/M, such as 99215-25, and link the asthma diagnosis (493.02, Extrinsic asthma; with [acute] exacerbation) to the inhalation treatment (94640, Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes).
 
When you report a CPT code for more than a problem-focused visit (level-two E/M codes and higher), multiple diagnosis codes indicate to the carrier the reason the visit supports a higher level of E/M coding that may merit higher reimbursement.
 
Try to avoid reporting "unspecified" or "other" diagnosis codes as the primary reason for the visit. The more specific you can be, the more likely you are to receive reimbursement - so if you need to discuss the patient's condition with the physician before assigning an ICD-9 code, don't hesitate.

 - Reader Questions and You Be the Expert were reviewed by Richard Tuck, MD, FAAP, practicing pediatrician with Primecare Pediatrics of Zanesville, Ohio.