13 coding pearls and a few trinkets

October 2004

To reduce harm to the financial health of your pediatric practice, “primum non nocere” should be adapted to coding. Correct CPT and ICD-9 codes are essential for obtaining the best third-party payer reimbursement for evaluation/management (E/M) and office visits. The following selection of practical coding pearls and trinkets have been field tested by me and, at least for the present time, seem to work in northern Virginia.

Pearl #1: Our practice insists that a pediatrician or nurse practitioner, not a nurse or receptionist, write in the numerical ICD-9 codes and circle the appropriate CPT code for each office visit. We strongly advise against written diagnosis, ie pharyngitis/tonsillitis, without the numerical code. We insist on numerical ICD-9 codes for pharyngitis/tonsillitis, ie 462/463, or the specific code 034.0 for streptococcal pharyngotonsillitis.

Pearl #2: To facilitate access to common pediatric ICD-9 codes, we have a three-ring binder in each examining room containing the most commonly used ICD-9 pediatric codes downloaded from the software program on our office computers and modified over time to include most ICD-9 codes used in office pediatrics. Other practices prefer that the physician or nurse practitioner carry and use a hand-held PDA with software for ICD-9 coding. Except when a specific numerical code is unavailable or hidden under an unusual name in the examining room ring binder or PDA software, we do not shift this responsibility to the nurse or office receptionist.

Pearl #3: The 99213 code is for the average pediatric sick visit and 99214 is for the more complicated sick visit, such as the chronically ill child with acute complaint or complex multisystem issues in addition to a review of the chronic problem, as long as specific guidelines have been documented to support the higher code. Also, prolonged service may be used with the lower code to capture the time.

Mechanical removal of deeply impacted cerumen in child with otalgia deserves separate mention. Although there is a separate CPT code for cerumen removal, 69210, many of the third-party payers in my area will deny the claim for the office visit plus the 69210 code. Third-party payers also routinely reject the use of the -25 modifier along with the 99213 CPT code for the average office visit. We have successfully circumvented this third-party obstacle by using the 99214 CPT code for office visits for acute otitis media (382.00) when it is necessary to laboriously remove large amounts of impacted earwax with aural lavage or stainless steel curette or both methods. Others have stated that the 69210 code without the CPT office visit code of 99213 gives better reimbursement than the 99213 code by itself.

Pearl #4: Every pediatric office must have a current copy of “Current Procedural Terminology: CPT 2004” and ICD-9 codes published by the American Medical Association.

Pearl #5: Strict employment of average time guidelines typically undervalues reimbursement for professional visits. Code choice should be based on systems documented and medical necessity.

Pearl #6:. In our office, CPT code 99213 accounts for approximately 75% of office visits for established patients. An estimated 15% of office visits for each pediatrician in our practice are coded as 99214 and another 5% are coded as 99215 or 99212. The remainder of office visits are CPT code 99211. The CPT code is based on complexity of the problem and not on the ICD-9 diagnostic code. We use the better-paying 99214 CPT code for management of moderate or severe acute bronchial asthma attack, evaluation of severe acute or chronic headache, severe acute or chronic abdominal pain, an ill child with Down syndrome who requires a time-consuming complete evaluation or a fever evaluation for a difficult-to-examine autistic child. Another example for the use of 99214 is the inclusion of a rectal exam in addition to the usual physical examination for complaints of abdominal pain or chronic constipation. CPT 99215 is the most labor- and time-intensive code for an office visit. When 50% of a 40-minute extended visit relates to counseling, education and coordination of care, this code can be used.

The use of multiple diagnostic codes with specificity should relay the complexity of the problem. Most auditors look at medical necessity to substantiate higher code choice. Documentation of what was discussed and when time is used is key.

Pearl #7: Formal consultation, by AAP definition, requires the three “Rs”: referral by another physician, reason for the requested referral clearly spelled out, and a written report. A common and costly mistake that undervalues the visit is to CPT-code preoperative clearance as 99213 or routine check-up code 99392, 99393, or 99394. Preoperative clearance for any scheduled surgical procedure is coded as a 30-minute consultation visit in our pediatric office (CPT 99402). Our third-party payers have honored this code for pre-op evaluations that fulfill the three R’s. A photocopy of the preoperative history/physical examination form should be kept in the patient’s chart to serve as evidence that the consultation by you was requested by the surgeon in order to clear the child for general anesthesia. If the surgeon is requesting clearance on an existing condition, payment will usually be made separately.

Pearl #8: Office laboratory tests: There must be a clear linkage between the diagnostic code and any laboratory procedure performed in the office. For example, an ICD-9 diagnostic code for sinusitis should not be linked to a rapid test for streptococcal antigen (rapid strep test). This non sequitur may tick off a polite refusal to pay for the throat culture. The first diagnosis in the example given should be sore throat linked to the rapid strep test. Dysuria or urinary frequency should be linked to urinalysis and urine culture and sensitivity, and tonsillitis and/or cervical lymphadenopathy should be linked to a rapid test for acute mononucleosis.

Pearl #9:. Off-hours codes: Insurers are increasingly acknowledging add-on codes to be used in addition to office visit codes: for example, 99054 for services on Sundays and holidays. Some managed care companies pay better for emergency visit codes rather than after-hours code, and only by trying out different codes with the larger third-party payers can one know which is the best code to use for the highest reimbursement. However, many third party payers feel ER codes are only supposed be used in an actual ER. Each practice should test the system in their area and with different third-party payers. Request the billing department to follow up to see which codes are accepted and which get the highest reimbursement. Saturday morning hours unfortunately do not merit additional reimbursement by most managed care plans.

Pearl #10: For the past four years we have been successful in charging the parent(s) an additional $10 fee for our evening and Saturday morning office visits. This charge is not billed to the third-party payer. We pay the office staff a higher hourly rate, and this is the stated reason for the evening and Saturday morning extra charge. Expect about 5% of the parents to take offense in the first four to six months after initiating such a policy. While many pediatricians are totally opposed to this charge, it has become the norm in many practices.

Pearl #11:. Code 99058 (emergency visit) merits a special discussion. If you, as a clinician, interrupt the normal flow of your office routine to care for an emergent situation, then you have satisfied the intent of this code. Think about the number of times your routine has been interrupted by a child brought in on an emergency basis. Try this 99058 code with specific 99214 office visits. Follow these charge slips for a few months and determine which companies will honor the 99058 CPT code and increase reimbursement for using it. Although this is appropriate to charge, some carriers may balk.

Pearl #12:. Every pediatric office should have a copy of the spiral-bound pocket version of the “Diagnostic and Statistical Manual” (DSM-4-TR) published by the American Psychiatric Association. Criteria and correct codes are clearly outlined for general anxiety disorder (300.02), major depressive disorder, social anxiety disorder, autistic spectrum disorder, nocturnal enuresis (788.36), encopresis, anorexia nervosa, specific substance abuse disorders and attention-deficit/hyperactivity disorder (ADHD). Payment denial for “psychiatric diagnoses” is sometimes a problem for pediatricians. However, knowledge and consistent use of the DSM-4-TR manual will reduce third-party payer denials of claims for service.

Pearl #13:. Every office should subscribe to one of the excellent, but a bit pricey, pediatric coding newsletters. Choose carefully, however, some are more helpful than others. One such newsletter is Pediatric Coding Alert (The Coding Institute, Naples, Fla., [800] 508-2582), which is priced at $247/year. Online versions are available for selected coding newsletters. The AAP publishes the excellent “Coding for Pediatrics.” Purchasers also receive gratis the AAP coding newsletter Pediatric Coding Companion.

A lagniappe of trinkets

Modifiers are two-digit add-on codes, appended to CPT codes. The Pedialink program for members of the AAP has an excellent online course on CPT modifiers, “2002 Coding Clues.” One modifier that pediatricians sometimes employ is -25. The -25 modifier is used when a significant, separate E/M service is performed on the same day. For example, if one is seeing a child for a well exam who also has a complex medical issue (eg, muscular dystrophy, cystic fibrosis) and that issue is also addressed during the well exam, then adding the -25 modifier to a “sick visit code” along with listing the well-exam code is appropriate. However, most insurance companies will not pay for two different services performed during the same patient encounter, and most insurance companies do not recognize modifiers such as -25. If a third-party payer rejects the claim, it creates extra work for your business office to appeal the rejection and it delays the time for you to receive payment for the claim. How long is your staff on hold when they attempt to learn why a claim is rejected for using a modifier? All experts unanimously recommend that rejected valid claims and CPT codes must be appealed and, if necessary, re-appealed. However, this is frustrating and time-consuming.

Consultation codes: The AMA and AAP definition of a consultation must have the three R’s: physician referral, not self-referral; reason for referral; and generation of a written report to the referring physician. I challenged this definition for several reasons. I completed a one-year fellowship in child psychiatry years ago, and as such I believe I am justified in performing and billing for my time under consultation codes 99401 (15 minutes), 99402 (30 minutes), 99403 (45 minutes) and 99404 (60 minutes). I have successfully consulted on our own patients without formal outside referral for ADHD, major depressive disorder, generalized anxiety disorder and disruptive aggressive behavior disorder. The relative value for 45- or 60-minute consultations is two to 2.5 times higher for a consult vs. an office visit, and by inference the payment is roughly two times higher for the service. Although guidelines say otherwise, there should be no reason why a pediatrician who keeps up with behavioral advances by continuing medical education sources should not have the right to consult on his/her own patients for complex issues. To do otherwise is arbitrary and wrongly undervalues our knowledge and time.

The above suggestion is, of course, contrary to the established guidelines for CPT consultation codes 99244 and 99245. Such consultation codes may be more acceptable to third-party payers if the pediatrician requests the child’s parent get the school teacher to suggest a formal consultation for behavioral problems from the child’s pediatrician. This third-party formal request may be invaluable evidence to support use of consultation codes. For those unwilling to experiment with CPT consultation codes, use of 99214 and 99215 CPT codes may be acceptable.

Fraud and abuse: Some physicians believe if they down-code their encounters, they are protecting themselves against charges of fraud and abuse. What they are really doing is undervaluing the care they provide. This is an untested and probably erroneous belief.

Cancellation charges: A telephone reminder one or two days prior to a routine health assessment (check-up) exam reduces the number of “no shows.” In addition, we directly charge a penalty fee of $20 for each child who does not notify our office of a cancellation at least five hours ahead of time. Anyone choosing this route must review carrier policies to determine if no show patients can be billed. Advanced written notice of intent to charge may be needed.

Concluding remarks

The office-based general pediatrician must learn to comprehend and profit from the sage advice of successful colleagues. Continue to test third-party payers every quarter- or half-year with CPT codes.

Carefully follow the third-party payments and denials of these trial balloons. Be kind enough to share your successes with your colleagues. Financial success and good pediatric practice deserve each other.

For more information:

• Richard H. Schwartz, MD, is from the department of pediatrics at Inova Fairfax Hospital for Children, Falls Church, Va.