Pediatric Coding Alert

These rules for billing levels of service may actually increase your reimbursement,and put you ahead of the game with private payers

The CPT documentation guidelines for E/M services are created for Medicare. Theres no dispute about this. But does this mean pediatricians, who do very little work with Medicare, can ignore these guidelines? No, our sources say. Thats because Medicare is bellwether when it comes to coding. Where Medicare goes, Medicaid and the private payers follow. If you are using the guidelines now, you will be prepared for whats coming. And if you do useand stick tothe guidelines, you can give commercial carriers a good argument if they refuse to recognize Medicare-accepted coding, like using modifier -25 when filing for a well visit and a sick visit done on the same day. You can ask your payers, How dare you go against HCFA? referring to the Health Care Financing Administration, which in addition to administering Medicare also writes CPT and the documentation guidelines with the American Medical Association.

Pediatricians who are in large multi-specialty practices or are affiliated with university hospitals are the most likely to be required to use the documentation guidelines. This is because the rest of the hospital departments have to use them in order to pass Medicare audits. But, even in these cases, pediatricians often resent having to do the documentation.

Our current auditing system is produced by the Medicare organization which has very little concern regarding pediatric care, writes a subscribing pediatrician who is with Hannibal Clinic, a multi-specialty practice based in Hannibal, MO. The clinic conducts internal chart audits throughout the year to evaluate the documentation, to make sure that it supports the level of service being charged. By using this Medicare system to audit our pediatric charts, we are attempting to impose rules and regulations which may be appropriate in the care of an adult, but are very inappropriate in the care of a child, the pediatrician concludes.

Unfortunately, the Medicare guidelines are the only documentation guidelines that exist, and they are to be used across all specialties, including pediatrics. The American Academy of Pediatrics (AAP) does have input into these guidelines, and works hard to try to get pediatric interests recognized by HCFA.

Pediatricians have a vested interest in using the documentation guidelines, because regulations that are implemented by Medicare are usually adopted by Medicaid and private payers, says Bela Agrawal, senior health policy analyst with the AAP. But its true that the federal government [HCFA] doesnt have a say over what the private payers and the state Medicaid programs do. And, as many pediatricians have noticed, commercial payers have a way of adopting some of the Medicare rules, but not all. But [...]