Wiki Chronic Care codes in Pediatric coding and billing

[ponkshe2003@yahoo.com]

I am a Coder and Biller at a pediatric Practice I have a question regarding CHRONIC CARE code 99358 for our Patients ( who are Complex care kids)
Here is my question:
Our complex care Patients if they come for WCC we bill once a year with Complex care code 99358 with their WCC as our Dr are reviewing their Charts before they come and managing their whole health.

So I put age based WCC with 25 Mod and 99358 code if the review time is 30-74 min on a complex care Patient.

My question is ANTHEM doesn't pay 99358 code so as discussed with you and my manager we add 99213/99214 ( whatever level) with their WCC code
to get paid on Chronic/complex care kids.

Please advise is that right? as one of our Pt mom complain that when they are bringing their child for WCC why do they have to pay a copay as we billed WCC and E/M code ( instead of 99358) to Anthem. What should we do in these scenario.

 

[Pathos]

Hello,

So first for the 99358 code, which is "Prolonged evaluation and management service before and/or after direct patient care; first hour".

The guidelines for this code is: "This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. A typical time for the primary service need not be established within the CPT code set."

Because this is a time based code, your provider will have to document time. The CPT book suggests documenting at least 30 minutes, but under the general Time guidelines, the lowest amount of time begins after the half point (31 minutes in this case).

That all said, Medicare generally doesn't pay for non-face-to-face visits, which is probably why Anthem is denying this service also.


Adding a regular E/M visit to a preventive visit can be tricky, but could be appropriate in certain cases. On a patient standpoint, I would feel a little mislead if I came in for a covered preventive visit thinking my visit is "free", and then ended up with a bill a couple weeks later. I understand the mother's concern for sure. From a coding standpoint however, if the documentation and medical necessity requires the regular office E/M visit, then I think you should be fine. However, as we all know insurances sometimes follow their own rules. Most insurances do not accept preventive visits with an office E/M modifier 25, however some still do.

Our clinic uses either/or (preventive or E/M visit), or have the patient reschedule the problem visit at a later time, or bill the type of visit which the provider spent the majority time on. For example, if the provider spent 50+% on the preventive portion, then a preventive visit would get billed out even if the provider spent time on the chronic issues.

Hope this is helpful!