Pediatric Coding Alert

When billing CPT 99173 , 99382-99383 and 99392-99393, knowing what to expect from payers will allow you to focus your appeals battles on denials that you can overturn.
 
"If your state Medicaid program does not cover a visual screening test (99173, Screening test of visual acuity, quantitative, bilateral) with a preventive medicine service (99382-99383 and 99392-99393), you can't do much to get the service paid," says Victoria S. Jackson, chief executive officer of Southern Orange County Pediatric Association in Lake Forest, Calif. But health maintenance organizations (HMOs) and managed-care organizations (MCOs) are a different story.

When private payer contracts come up for review, good statistics may convince the insurer to pay for 99173. "If you can show the HMO/MCO that covering the service costs them less than paying for ophthalmology-performed screenings and long-term vision problems that may result from not performing the vision screening, you may win 99173 coverage," Jackson says. Therefore, knowing your carriers' policies will help you choose which payers to target for appeals and contract reviews.

This is a partial list of Medicaid programs and commercial payers that bundle 99173 with 99382-99383 and 99392-99393:
 

Medicaid: California, Mississippi, Missouri, New Mexico, North Carolina, North Dakota, Ohio, Texas
 

Private payers: Aetna (New Jersey), AmeriHealth (New Jersey), CareFirst Blue Cross Blue Shield (BCBS) Maryland, BCBS of Tennessee, BCBS of Rhode Island, Cigna (New Jersey), Horizon BCBS of New Jersey, Horizon/Mercy (New Jersey), United Healthcare (Rhode Island).
 
Despite the lack of coverage, some policies cover the vision screening. Regence BCBS of Washington now covers vision screening for children during preventive-care visits. If the member is 3 through 11 years of age, the healthcare plan will reimburse 99173 in addition to 99382 (Initial comprehensive preventive medicine evaluation and management of an individual ...; early childhood [age 1 through 4 years]), 99383 ( late childhood [age 5 though 11 years]), 99392 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]) and 99393 ( late childhood [age 5 though 11 years]). For instance, Montana Medicaid pays 55 percent of the billed charge for 99173. A few other plans also cover the screening test:
 

Medicaid: Alabama, Arkansas, Delaware, Indiana, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Montana, Nevada, New Jersey, Virginia
 

Private payers: Cigna (Rhode Island), Oxford (New Jersey), Regence BCBS of Washington, Tufts (Rhode Island).
 
Note: Because this is a partial list, subject to payers' changing rules, be sure you verify coverage.