Coding Strategy

Uncircled vaccines, administrations could cost your practice 10%.

Think increasing payments in 2010 is a fairy tale? Your magic wand is right at your front desk.

“Check-out coding can have a significant financial impact,” reported Norman “Chip” Harbaugh, MD, in “Vaccine Reimbursement — Quite a Quandary” at The Coding Institute’s December 2010 Pediatric Coding and Reimbursement Conference in Orlando. Not having the check-out person make sure the pediatrician circles all performed services and procedures can cost a practice with median collections of $556,000 between 2.2 percent to 10.2 percent or $12,340 to $57,000.

To shore up those payment holes, train your front desk staff to spot two signs of overlooked coding opportunities.

#1:Verify 90476-90749, 90465-90474 on Crying Departees

If you have a well child age two or younger who comes to the check-out window crying, there’s a good chance he’s just received his needed shots. The pediatrician may have circled the appropriate preventive medicine service code — 99381 (Initial comprehensive preventive medicine evaluation and management of an individual … infant [age younger than 1 year]) or 99382 (… early childhood [age 1 through 4 years]) for new patients or 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual … infant [age younger than 1 year])or 99392 (… early childhood [age 1 through 4 years]) for established patients. She, however, may have forgotten to code the vaccines (90476-90749, Vaccines, Toxoids) or the administrations (90465-+90474, Immunization Administration for Vaccines, Toxoids). “Our coder has been reporting only the vaccines without the administration,” one physician conference attendee reported.

Tip: “The more eyes you have watching the charge ticket and entry, the more likely you are to avoid missed codes,” Harbaugh pointed out. On a less than two years of age well visit check-out in which the toddler is crying, you can train your check-out staff to ask, “How did the vaccines go?”

Let’s say the mother responds, “No, Suzie didn’t receive any vaccines.” The checkout person knows, “OK, 99381, 99382, 99391, or 99392 as the only CPT code is right,”explains Harbaugh, a primary care pediatrician practicing in Atlanta.

If the mother responds, “Three at one time is so hard,” the check-out person can then check with the nurse or medical technician to find out which vaccines the patient received. On the charge ticket, the check-out person can then add the appropriate administration and vaccine codes.

Example: Suppose the child received MMR, DTaP, and Hib at her 15-month preventive medicine service. The check-out attendant would circle:

For the vaccine products:

• 90707 — Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
• 90700 — Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
• 90648 — Hemophilus influenza b vaccine (Hib), PRPT conjugate (4 dose schedule), for intramuscular use.

For three shots with physician counseling given to a child less than 8 years of age:

• 90465 — Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day (0.58 relative value units [RVUs])
• +90466 — … each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure) (0.29 RVUs)
• +90466.

$avings: Catching the vaccines and immunization administrations saves the practice approximately $224. Missing the administrations alone costs you approximately $42 using the 2009 Medicare Physician Fee Schedule and conversion factor (CF) of 36.0666. The breakdown includes $20.92 for the initial administration and $10.46 for each of the two subsequent administrations. Combined with losses of $107.25 for the vaccine products (based on average reimbursements) and $74.28 in capital vaccine investment using Harbaugh’s calculations, you would have had a total loss of $223.53.

#2: Let Your Ears Alert You to Injections

Eavesdropping may not be de rigueur, but you can use overheard conversations to catch missed services. “In the ideal (prepayment) coding process, the doctor checks off the code and diagnosis on the superbill and the staff reviews it and catches any errors,” explains Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J.

Let’s say a pediatrician evaluates a patient for croup and the check-out staff heard the physician tell the nurse to give the patient a Decadron shot. The pediatrician didn’t mark “Injection” on the charge ticket. The checkout person checks with the nurse who concurs that the patient received a shot, and the staff then codes the:

• injection administration with 96372 (Therapeutic,prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)
• drug supply with J1100 (Injection, dexamethasone sodium phosphate, 1 mg).

$avings: Catching that the patient received an injection adds a deserved 0.58 relative value units or approximately $21 to the claim, according to the 2009 Medicare Physician Fee Schedule, which uses a national conversion factor of 36.0666. Most payers adopt this resource-based relative value system in some fashion. The Medicare payment limit for J1100 is $0.09.

@ Pediatric Coding Alert, Editor: Leigh DeLozier, CPC

Want to know more? Sign up for the upcoming live audio conference, Take the Sting out of Coding Infusion and Injection Services, or order the CD/transcripts.

Be a hero. Sign up for Supercoder.com, and join the coding community at the Supercoder.com Facebook Fan Page.

Hint: Gathering upfront pay and watching E/Ms make a difference.

Children need physicals to participate in their favorite sports year round, but the demand can grow with warm weather approaching. Ideally, the need for sports physicals should provide the opportunity to offer complete age-appropriate medical exams following the American Academy of Pediatrician’s Bright Futures Guidelines. If your practice runs into reimbursement obstacles for full-scale physicals, however, follow our experts’ advice to code correctly and still stay in the game.

Tackle Coverage Issues

Choosing the diagnosis code for a sports physical is fairly easy. You’ll use V70.3 (Other medical examination for administrative purposes).

Choosing the best CPT code for a sports physical is a bit trickier. “I struggle with this because the service rendered is preventive, but doesn’t meet the criteria (in my opinion) of the preventive medicine E/M codes,” says JoAnne M. Wolf, RHIT, CPC, coding manager for Children’s Physician Network in Minneapolis, Minn.

Here’s why: In most cases, a child coming for a sports physical doesn’t have a chief complaint, so it seems inappropriate to code from the 99201-99215 range (codes for an office or other outpatient visit for the evaluation and management of a new or established patient), Wolf points out.

Although the preventive medicine E/M codes 99381-99397 (codes for initial or periodic comprehensive preventive medicine evaluation and management of an individual) satisfy the requirements for sports physicals, they also seem inappropriate. When the patient only requests a sports physical, the service you provide doesn’t meet the codes’ comprehensive nature.

“Physicals are a very hard topic to discuss because some insurances will not cover them at all and some will cover them in different ways,” says Susie Stokes, CMC, CMOM, practice manager of Morgan Pediatric Group in Smyrna, Tenn.

Common guidelines can include:

• One per calendar year
• One per year following the patient’s birthday
• One after one year and one day after the last physical.

Other complications can arise because of the sports organizations’ rules. For example, Stokes says most school sports in her area require a physical after May 1 of the current year. If the child had a physical before May 1 and the sports league requires it after May 1, the parents have a dilemma: They don’t want to pay for another physical and the insurance provider will not pay.

“In this case we go ahead and sign the form and date it the date of the physical with all the information,” Stokes says. “Then if the association wants another physical, the school explains it to the parents so we don’t look like the bad guys.”

Good practice: Your first step should be to ask patients to pay cash for the sports physical (especially those with insurance you know doesn’t cover the service). If the parent insists that insurance will cover the exam, assure the family that your practice will file a claim and reimburse the parent if insurance does pay.

Pitch Preventive Visit Instead

If the patient’s insurance includes a yearly preventive medicine service, you can offer that service in lieu of the sports physical and maximize the patient’s benefits — pluskeep your coding clean. AAP recommendations supportthis approach.

“Many of our clinics will perform the full preventive medicine service at the time the patient presents for a sports physical,” says Wolf. “Adolescents and teens are age groups that do not tend to come in regularly for their preventive services, so our clinics try to take advantage and get the complete well visit done at that time.”

New tactic: Your coding will change if you’re able to provide a preventive care visit. Choose the best code from 99381-99385 (Initial comprehensive preventive medicine evaluation and management of an individual …) based on the patient’s age for a new patient or from 99391-99395 (Periodic comprehensive preventive medicine reevaluation and management of an individual …) based on the patient’s age for an established patient.

You also have two choices for the preventive examination’s diagnosis. Select V20.2 (Routine infant or child health check) for children up to age 18. For those over 18, shift to V70.0 (Routine general medicalexamination at a health care facility).

Catch Extra Services

Watch for additional coding opportunities with these patients, because a sports physical might extend to include other services.

If the pediatrician provides a problem-oriented E/M service for a separate, significant problem in addition to the sports physical or preventive medicine service, you also can code for it.

Next step: Once you select the appropriate E/M code, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to that E/M code and include documentation supporting the care as an additional service.

You should be able to link the E/M code to a specific diagnosis for the problem addressed, such as 493.00 (Extrinsic asthma; unspecified) for asthma that is well controlled with medication or 314.01 (Attention deficit disorder; with hyperactivity) for ADHD managed with stimulant medications.

Head Off the Competition

Another challenge with sports physicals lies in the ever-growing number of “retail” clinics that offer quicker testing and less costly services. Stokes and Wolf agree,however, that convenience doesn’t equal quality.

“We don’t do what people call the quick sports physical,” Stokes says. “We understand the parents want something fast, but we’re clearing these kids to play sports and we have to take the appropriate amount of time to make sure they’re in good health to play.”

“Many of the primary care pediatric clinics in our network have countered the retail clinics by offering ‘walk-in’ services during regular clinic hours,” Wolf adds. “They also offer extended weekend and evening hours.”

@ Pediatric Coding Alert, Editor: Leigh DeLozier, CPC

Be a hero. Sign up for Supercoder.com and join the coding community at the Supercoder.com Facebook Fan Page.

Want to know more about pediatric coding? Attend this upcoming conference or order a transcript/CD: The Nuts N’ Bolts of Pediatric Coding.

Tip: Time-based E/M might be in line when managing diabetes, asthma, ADHD.

Overlooking time as the key factor on a camp or sports exam in which the patient has a problem could cut $30 per claim.

Opportunity: An office visit (99201-99215, Office or Other Outpatient Services) using time as the key factor might be appropriate, but keep in mind that lowballing time-based E/M codes because of poor documentation can be a revenue-loser for many practices, says Jennifer Godreau, who’s presenting a free webinar next week to help coders tackle trouble-spots.

Watch for Chronic Conditions

“If there is a chronic medical problem to update, e.g. asthma, we often use that diagnosis code (such as 493.00, Extrinsic asthma; unspecified) and code by time, as counseling will often be more than 50 percent of the visit time,” says Marc Tanenbaum, MD, FAAP, a pediatrician with Pediatrics and Adolescent Medicine in Atlanta.

The patient’s health problem might affect his ability to participate in a certain camp activity or type of camp. “I’d want to do a more recent assessment and some updated counseling regarding the patient’s health issue and how to handle any potential problems that might arise at the camp,” notes Nancy Bishoff, MD, FAAP, a private practice pediatrician in Lexington, Ky.

Be Alert to Counseling Time

When coding based on time, careful complete documentation of the time elements is a must, including total face-to-face time, and minutes spent counseling and/or coordinating care. Also include a brief sentence related to the general areas discussed during the time.

Check out how the key components of history, examination, and medical decision making (HEM) versus time measures up in this example: A teenage boy with benign hypertension (401.1, Essential hypertension; benign) wants to attend survival camp. The pediatrician performs an expanded problem focused history, an expanded problem focused examination, and low complexity medical decision making, which qualifies as 99213 based on HEM. The pediatrician documents she spends 15 minutes counseling the patient on hypertension management and the visit lasts 25 minutes.

Because counseling comprises the majority of the encounter’s total face-to-face time, you can code the visit using time as the controlling factor and select 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity … Physicians typically spend 25 minutes face-to-face with the patient and/or family). If you had overlooked this fact and instead coded 99213 based on HEM, you would have sacrificed approximately $31* in pay.

*Note: The 2009 Medicare Physician Fee Schedule, which you can use as a benchmark to judge private payers’ fees, assigns 2.56 relative value units to 99214.

Using the conversion factor of 36.0666, 99214 pays approximately $92. Code 99213 has 1.70 RVUS, which equates to approximately $61.

Heads Up on Other Disorders, Diseases

Some other examples of chronic conditions that might warrant an updated history, exam, and counseling are diabetes (for instance 250.01, Diabetes mellitus without mention of complication; type 1 [juvenile type], not stated as uncontrolled) and ADHD (314.01, Hyperkinetic syndrome of childhood; attention deficit disorder; with hyperactivity).

@ Pediatric Coding Alert

Can’t wait for Jen’s free webinar to start your search for lost cash? Go to Supercoder.com, and get the latest expert advice.

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Sort your normal, sick and intensive care options.

Choosing the appropriate codes for initial newborn services can be difficult due to the large number of available codes and gray areas between the spectrum of illnesses. If you find yourself getting tripped up by the multiple categories, read on for expert tips and real-world examples that will point you in the right direction every time.

Normal Care Means No Problems

A “normal” newborn has no medical conditions or need for special care. Report the history and examination with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant).

Donelle Holle, RN, a consultant with Pedscoding.com in Indiana says this initial care includes five things:

• Maternal and/or fetal and newborn history

• Newborn physical examination

• Ordering of diagnostic tests and treatments

• Meetings with the family

• Documentation in the medical record.

Diagnosis tip: When billing with 99460, include diagnosis V30.x x (Single liveborn). “Because 99460 states ‘normal newborn,’ you cannot have any other diagnosis for that CPT code,” Holle explains.

Add-ons: Procedures such as circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes (99460-99463). Be sure to code the circumcision in addition to the newborn care. To indicate 99460-99463 is significantly identifiable from the minor E/M included in surgical codes, append 99460-99463 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Sick Newborn Needs Inpatient Codes

When the pediatrician provides E/M services for newborns who are other than normal, CPT directs you to report the codes for hospital inpatient (99221-99233) or neonatal intensive (99477-99480)  or critical care (99468-99469) services.

A baby considered a “sick” newborn might have a fever, high hemoglobin count, or MILD RESP DISTRESS. For a sick newborn, you’ll select from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) for the first day, based on the level of history, examination, and medical decision making.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The physician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn’s care with the appropriate choice from 99221-99223.

Intensive Care Require Extra Monitoring

Sometimes infants and neonates are not critically ill but need intensive cardiac or respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, nutritional adjustments, or laboratory and oxygen monitoring. These babies also require constant observation by the health care team under direct physician supervision.

“These infants are not critically ill but do require further monitoring or services that MAY require them to be in the neonatal intensive care unit (NICU),” Holle says.

Remember the level of care delivered — not the site of service — determines the code you choose, says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Intensive care codes could apply to a baby in the newborn nursery or NICU.

Example: An infant is born at 37 weeks gestation with mild tachypnea and requires 30 percent O2 by nasal cannula. The pediatrician acquires cultures and initiates IV antibiotics. Close monitoring is maintained; no additional intervention is indicated.

For the first day of this baby’s care, report 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services). Additional days should be coded according to the infant’s status.

• “If the neonate continues to require intensive monitoring, frequent interventions, observation, or other intensive care services, use the low birth weight or recovering infant codes,” Holle says. Choose from 99478-99480 (Subsequent intensive care, per day, for the evaluation and management of the recovering infant …), based on the infant’s weight.

• If the child is still ill but no longer requires intensive or critical care services, Holle says to select from 99321-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

• “Sometimes a child moves from being intensively ill to being ill, to being well,” Tuck explains.  Once the child is well, turn to 99462.

What should you report if neonates meet critical care status? Subscribe to the Pediatric Coding Alert or go to www.supercoder.com for the answer.

Want to know more? Sign up now for Dr. Richard Lander’s Pediatric Coding: Simple as ABC audioconference before it’s sold out!

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How to use technology to speed up new patient check-in.

Not enough hours in the day? Are you always looking for ways to save time? Many medical offices report that sending out new patient packets in advance of the patient’s visit greatly reduces the number of incidents at patient check-in and saves time.

“Normally, it would take patients 15-plus minutes to complete the forms,” says Stephanie Mayer, front desk receptionist for a pediatrician in Queens, NY. “Also, there is the distraction of other patient activity in the waiting room, which could keep patients from concentrating on forms they are supposed to complete.”

Put forms online

If you are not already doing so, talk to your practice administrator about putting new patient packets online.

“Sending or having a patient access our packets from our Web site gives the patient the opportunity to input the information leisurely and accurately, and if needed, the time to research dates, reference medications, and obtain past medical history, says Suzanne E. Keith, practice administrator at Michael W. Goodman, MD, PC, in Chattanooga, TN. “Also, bringing or e-mailing the information in advance allows our office to make a chart and reduces the patients’ wait time.”

Their new patient packet is available online and the patient may download and print the forms and email, fax or carry them to their appointment. Patients can open forms directly from the Web site, or they can download the forms to their computer and open from there. Right now, 30 percent of their patients are using the online forms.

Other site benefits:

• saves on postage, paper and envelope costs;

• provides a resource for patients for medical information;

• answers most questions that a patient may have about the practice and their doctors; and

• cuts down on calls about office hours, location, and directions.

New patient packets should include:

• A demographic sheet with insurance information, medical history, and assignment of benefits;

• HIPAA privacy practices and receipt; and

• Release form for protected health information

Note: If you mail new patient packets, you should send them out at least five days prior to the patient’s appointment.

What’s left to do?

According to Klein, when a new patient packet is received, you should:

1. Double check to make sure that everything is filled out properly and signed.

2. Confirm insurance information.

3. Input information into the system and start a new chart. If it is a patient referral, you should already have a copy of the chart from the referring physician.

4. After reviewing the packet, scan or copy the patient’s insurance card and driver’s license.

“In our office, we ask the receptionist to paperclip the medical history to the front of the chart and then call the nurse to make her aware the patient is there and ready to be seen,” Keith adds.

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