Pediatric Coding Alert

Don't let your practice pay the price for children who took in some rays over spring break. Instead, add a cool $23 per visit with 16000 rather than 99213. Some pediatric practices may not realize that unless a burn visit qualifies for CPT 99214 , they can receive more reimbursement with the code for first-degree burn initial treatment (16000), says Sherry Wilkerson (Straub), RHIT, CCS, CCS-P, coding and compliance manager for Esse Health in St. Louis. Knowing which codes to use, whether an E/M is also justified and the diagnoses to assign will peel away old methods and rejuvenate your practice's bottom line. Many pediatricians are unaware that the burn codes exist, says Kay Faught, coding consultant for CPT Coding and Clinic Management in Jacksonville, Ore. "Consequently, the physicians report an office visit code only, which undervalues their services," she says. Because treatment codes generally pay more than E/M codes, practices that fail to use the burn codes suffer financially. "With increasing capital costs and shrinking reimbursement, pediatricians cannot afford to sacrifice codes that they are entitled to bill," Wilkerson stresses. Show Me the Money The burn codes that pediatricians use in the office usually pay more than office visit codes. For instance, after vacationing in Florida, a parent brings in a child whose pale midwestern skin could not tolerate the sunshine. The patient's back is red from a first-degree burn. The pediatrician performs a simple cleaning of the sunburned area and applies an ointment. Because the physician in this example provided initial treatment of a first-degree burn, you should report 16000 (Initial treatment, first-degree burn, when no more than local treatment is required), which carries 2.02 relative value units (RVUs) and reimburses at an unadjusted rate of $74.32, based on the Medicare Physician Fee Schedule (MPFS). (Although pediatricians usually do not have patients on Medicare, the MPFS gives the Medicare allowance, which can be used as a benchmark to which you can compare other insurers. Private payers may reimburse more.)

To reach this same reimbursement level, the visit would have to qualify for a level-four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient physicians typically spend 25 minutes face-to-face with the patient), which has 2.17 RVUs and pays $79.83, according to MPFS. "Most pediatricians, however, code minor sunburn with 99213 or less, which results in less reimbursement than if the doctors billed 16000 for these services," Wilkerson says. If the visit meets the criteria for a level-three office visit, reporting 99213 (Office or other outpatient visit for the evaluation and management of an established patient physicians typically spend 15 minutes face-to-face with the patient) instead of 16000 would [...]