Pediatric Coding Alert

Are you minimizing revenue by using an E/M instead of a procedure code?  Stop insurers from balking at your procedural code claims and compare your services to other offices with this ready-to-go common pediatric agenda.

Declining dollars for pediatricians and increasing costs of delivering care mean you can't leave any revenue-producing stone unturned. "One of the best ways to increase revenue is to provide and code for procedures," says Victoria S. Jackson, pediatric practice management consultant with JCM Inc. in California. You can get paid at a higher rate for simple in-office services simply by correctly using a procedure code.

But one coder ran into a snag with this tip. An insurer wasn't reimbursing for certain (ancillary) procedures: cerumen removal and suture removal, says Bill Roy with Kidz Doctor LLC, the office of Cora Cerdena, MD, a
pediatrician in Summit, N.J. When he notified the insurance company of his plan to terminate the contract based on nonpayment for procedures, the representative requested a list.

If you need a list of reimbursable procedures to submit to an insurer or want to make sure you're optimally capturing services you're providing, check this list of other performed pediatric procedures compiled by Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J.

"For anything else you do, look it up in CPT," he says. (The chart uses National Physician Fee Schedule transitional nonfacility total relative value units [RVUs] with the  2007 conversion factor of 37.8975.)

Take Advantage of Nonphysicians' Procedures Too  Procedures that staff usually perform also have their own procedure codes. The nurse (RN) or medical assistant (MA) reports these incident-to* the pediatrician. The list on page 38 does not include screenings or immunizations.
 * Remember: Incident-to services require physician presence in the office suite but not in the room with the patient during the procedure. The nurse or technician should separately document the "incident-to" service, which the supervising physician should countersign.