Pediatric Coding Alert

This months columnist, Charles Scott, MD, FAAP, is vice president-elect of the New Jersey Chapter of the American Academy of Pediatrics (AAP) and a regional coding trainer for the AAP. Scott practices with Medford Pediatric and Adolescent Medicine in Medford, N.J. and is acting chair of the department of pediatrics at Virtua-Memorial Hospital in Mt. Molly, N.J. On his days off (every pediatrician in the practice gets one day off a week) he works as a school physician or does exams at a juvenile detention center.

Recently, some of my colleagues in the area were shocked by a letter from Cigna. Heres what the letter says:

Effective March 1, 2000, in order to be paid for a Level 4 or Level 5 evaluation and management (E/M) code, it will be necessary to submit a copy of the medical record documenting the level of service with the HCFA 1500 claim form. Any claim submitted for a Level 4 or 5 E/M code without adequate documentation of the higher level of service will be paid as a Level 3 E/M service.

The above policy is what I would call the tip of the iceberg. While this policy only applies to some Cigna products, the letter makes it clear that the rule only applies to Cigna HealthCare/Premier Plus products, not to the Cigna PPO, Cigna HealthCare of New Jersey, Cigna HealthCare of New York, or Cigna for Seniors productsat least not yet.

I have no problem with an insurance company coming in and auditing me. They dont even have to suspect meit can be a random survey. But the Cigna rule is making it impossible to bill any Level 4 or Level 5 electronically. Its assuming were all guilty. And what so-called expert will decide the validity of the use of the code? This could be someone who didnt even go to high school. At least with an aditor, its a nurse.

In the New Jersey chapter of the AAP we talked about several possible reactions to the Cigna policy.

1. Make phone calls. We can call Cigna and any other company that makes a rule banning upper-level codes without documentation.

2. Discuss a boycott. Depending on your situation, you can discuss a boycott. My group has 50 pediatriciansone practice, one tax ID. We can legally negotiate. So we can talk about dealing with this problem en masse without running afoul of antitrust laws.

3. Use practice audits. The AAP wants to propose to Cigna that a few practices have their charts audited to determine whether the use of the E/M codes is correct. I have volunteered our practice for this audit. In our practice, 30 percent of the codes are Level 4, and 50 to 55 percent are Level 3. Pediatric coding experts will suggest that a pediatric practice should have 15 to 40 percent of the visits in the Level 4 and Level 5 rangemost likely around 25 percent. Fifty to 60 percent should be Level 3, and 20 percent should be Level 2. Now, this may change depending on what kind of patient you have. Practices with many chronically ill children will have more higher-level codes.

If I have to send in 25 percent or more of my claims, that is going to be a big problem, because we file electronically. Im not worried about my documentation, though. I dictate my charts. I put a lot of information inabout how the child looks, about the lungs, heart, abdomenI probably put enough in most of my dictation to move the level to a four.

4. Talk to your representative. I urge all pediatricians to contact their congressional representatives about proposed federal legislation that would give physicians the right to negotiate through their associations, essentially avoiding antitrust laws. Since managed-care companies are consolidating, they have more power to force things down our throat. We need to have some power, too.