Pediatric Coding Alert

Question: We would like to know when an insurance company denies a procedure and states “denied- not a covered benefit,” should the EOB stipulate whether the patient can be billed for this procedure? For instance, patient came in for a well visit and had the visual acuity screen done. We bill a CPT code 99173 with an ICD-9 code V20.2 and the insurance denied it as a non-covered benefit, but the EOB does not say “do not bill member” or “member may be billed.” Can we bill the patient?

Tennessee subscriber

Answer: Not all insurers specifically state on the EOB whether or not the member should be billed for the balance, but unless your contract indicates otherwise, you can typically bill the patient for the non-covered service once the insurer denies it.

Of course, if you know up-front that a particular service won’t be covered, ask the patient’s parents to sign an ABN agreeing to pay for it. This way, there is no confusion when they get a bill from your practice for the service.

Basics of 99173: CPT permits billing a vision screening provided with a preventive medicine service. Regardless of that, many managed-care organizations (MCOs) bundle the screening test with well-child healthcare.

Some Medicaid programs reinforce coding 99173 regardless of coverage. For instance, North Carolina Medicaid guidelines indicate that you should list vision screening CPT codes in addition to the preventive medicine CPT code. Despite this directive, the carrier allows no additional reimbursement for 99173.

However, before you blame noncoverage on the insurer, make sure you link the vision test to a different diagnosis than the preventive medicine service. CPT does not require separate diagnoses to reimburse a same-day E/M and other service. Using different ICD-9 codes, however, will help show the payer that the pediatrician performed two separate services.

Therefore, you should link V72.0 (Examination of eyes and vision) to 99173, and link V20.2 (Routine infant or child health check) to 99382-99383 and 99392-99393. In addition, depending on your insurer, you may need to append modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the appropriate preventive medicine service code.

Keep in mind: As a general rule, if a plan indicates a service, in this case vision screening, is included in the preventive medicine service, your battle is with the insurance company and you can’t balance bill the patient. If, on the other hand, they indicate it’s a non-covered service, you can balance bill the patient (an ABN is optimal).