"sick" well visits

>
>I agree with Dr. Adler. His way is generally what I have been doing. Now,
>I will double code some well visits if a reasonable amount of time was
>spent covering a "sick" concern and yet all the components of the well
>visit were fulfilled. I really like the way Texas Medicaid is set up --
>you can refer the "sick" well-visit child to yourself as the primary care
>physician and separately charge for this sick care. This is fair when it
>significantly prolongs a regular visit. My billing secretary says that
>even if I double code the well visits with a child who is also sick, only
>one of the codes are being paid by the non Medicaid insurance's. I hope Dr
>Pillsbury from the AAP is still on this list and can tell me if we could be
>coding these visits in any other way. I'm not sure I've explained myself
>well- it's been a long day. Kim Burlingham, MD
>
>

The mechanics of the CPT/ICD9 aspect of this is actually quite easy, the ramifications are something more complicated.

1) Bill the well portion using CPT preventative code 99381 - 99394 and
ICD code V20.2 (well child).

2) Bill the "sick" portion using CPT code 99201-99215 and the appropriate diagnosis.
Consider only the "sick" time & effort for this portion above and beyond what you
did for the well portion when determining this code.

Send a copy of the office note with the claim if you find this combination getting routinely denied, and be prepared for multiple appeals if you really want to get paid from an uncooperative company. It's usually not cost effective to mount an appeal, but I've spent 30 minutes or more doing paperwork in order to get paid $20.00 extra just so I wouldn't leave the last EOB stating "visit not medically necessary" (it's definitely a pride and principal thing!)

One insurance company stated outright that their computer claim-check system will always kick out and deny the above combination as "two visits in one day" and to not even bother trying. They suggested billing a 99214 or 99215 if the visit was truly comprehensive and the note can justify the coding.

Another company actually sent a letter stating that they would pay this type of billing if a complete office note is included with the claim. I enclose a copy of that letter when submitting these types of claims and they still get routinely denied. When I spoke to the director of medical review (yes these people really exist) and he personally reviewed some denied claims, he agreed my billings were all appropriate (and he would reverse those denials) but I would just have to keep appealing future denials. This brings up the "qualifications" of the low level medical reviewers, but that's another posting.

Lastly, some plans have a single co-pay "per office visit", and will deduct two co-pays when a single encounter is billed this way as "two office visits". Will you charge the patient double the amount their insurance card says they're supposed to pay you? And we know that forgiving co-pays is another legal and ethical topic ripe for further discussion.

The CPT manual discusses this topic in more depth. And if your office doesn't have Pediatric Procedural Terminology from the AAP, buy a copy. It's a cliche but you'll be glad you did.

Michael Sachs, M.D.
General Pediatrician