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Codes and Payors:
2009 Pediatric Update
Presented by
Lynn A. Brown, CPC
September 18, 2009
ABOUT THE SPEAKER
Lynn Abernathy Brown, CPC has over twenty years of
experience in medical record coding and reimbursement in a
physician office setting.
Lynn is employed by Children’s Health System as the Director of
Physician Coding and Reimbursement. She is proficient in ICD9-CM and CPT coding principles specializing in pediatric
physician reimbursement issues in the State of Alabama. She
is a member of AAPC, MGMA-AL, and 2009 Chair of ALChapter-AAP Practice Management Association, serves on the
AL Medicaid/MASA Coding Workgroup and the AL-AAP
Pediatric Council.
DISCLAIMER
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The material in this handout is prepared by the presenter and
are statements of fact or opinion based on information from
various insurance providers, internet website and other sources
available in the medical profession. The statements in no way
guarantee payment from any insurance provider and do not
imply an opinion or guarantee by Children’s Health System.
I have no financial relationships or interests with proprietary
entities producing health care goods or services related to the
content of this CME activity. My content will not include
discussion/reference of any commercial products or services. I
do not intend to discuss an unapproved/investigative use of
commercial products/devices.
Needs and Objectives
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Update physicians/staff regarding payor changes in
Alabama related to CPT and ICD-9-CM coding;
Familiarize physicians/staff with major payor medical
policies and resource information related to
appropriate coding;
Be familiar with appropriate use of CPT modifiers;
Understand medical record documentation
requirements which support CPT and ICD-9-CM
coding from payor/auditor’s perspective.
Blue Cross-Blue Shield
of Alabama
BCBS-AL CHANGES
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BCBS rules changed 01/21/2009
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Allow modifier 25, 59
Allow Preventive and Sick for Pediatrics only
Allow Procedures and E/M Codes on same DOS
Majority of contract should only require one
copay for Preventive and Sick visit on same
day
PREVENTIVE AND SICK

Sick Levels (99214/99215) create target for
auditor; documentation must support

Modifier 25 use on auditing radar

Most Sick Visits with Preventive Visit will be
at least one level lower than if they had Sick
only
Documentation for Well and Sick

Separate Documentation Required
PREVENTIVE CARE
VISIT
• Comprehensive History
• Comprehensive Exam
(including documented sick
body area/organ system
SICK VISIT – Mod 25
CC
HPI
MDM
E/M VISIT and 17250

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BCBS – AL automatically pays for
Preventive Care with Modifier 25 and
17250 (Silver Nitrate Stick) umbilical
cauterization
BC does not automatically pay Sick visit
and 17250 (Silver Nitrate Stick) umbilical
cauterization (must appeal)
BCBS NEWBORN FOLLOW-UP
Mgmt of Hyperbilirubinemia in Newborns
• BCBS-AL allows V Codes for Newborn 1st visit
• Other payors may not allow same V code
CPT codes: 99201-99205 and 99211-99215
First few days after discharge [see policy guidelines]
V29.3
• Observation and evaluation of newborn for suspected genetic
or metabolic condition
V29.8
• Observation and evaluation of newborns and infants for other
specified suspected condition not found
Alabama Medicaid
AL MEDICAID UPDATES

Medicaid no longer requires UA at EPSDT

96372 requires modifier 25 on E/M
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NDC number required for generic Rocephin

NDC update to claim now on webportal

Well Baby Care changed to 99460
MCD MODIFIER SCENARIOS
Paid without modifier 25
99391-EP Preventive Care < 1yr
17250 - Cauterization
Paid with modifier 25
99213-25 Established visit Level 3
96372 – Injection Administration
No payment with any EP modifier
for Injection Administration
99391-EP Preventive Care < 1yr
96372 – Injection Administration
Synagis Administration will not be
paid on same day as EP Screening
AL MEDICAID-WELL BABY CARE

99432 99460 [Medicaid only] effec. 1/1/09
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First 8 weeks of life
One time code
Does not go against 14 visit limit per year
Allows EPSDT screening at 2 – 4 weeks
QTOOL - MEDICAID STATEWIDE EHR
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ePrescribe
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BCBS-AL and AL Medicaid claims data

Diagnostic Testing History

Prescription History
Contact Kim Davis-Allen for set-up
[email protected]
COUNSELING FOR VACCINES
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If counseling goes long due to parental
refusal consider using the preventive
medicine counseling codes
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99401: preventive medicine counseling and/or
risk factor reduction intervention provided to an
individual; approx. 15 min
99402: approx. 30 min
99403: approx. 45 min
99404: approx. 60 min.
COUNSELING FOR VACCINES (cont)

AAP recommends using these codes when the
counseling on a vaccine is more involved than normal
instead of the vaccine counseling codes.

Document the amount of time spent counseling
and a brief description of the counseling

Example: “Spent 15 min. discussing the vaccines
required at 2 months and Mother states is concerned
about autism. Discussed pro’s and con’s of vaccines,
media information etc.” Bill 99401.
99401-99404 COVERAGE
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BCBS-AL not included on PMD fee schedule
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Medicaid allows 99401 and 99402
Care Plan Oversight
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BCBS-AL
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Per PMD fee schedule, CPO codes not included
AL Medicaid
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Per Medicaid Fee Schedule, 15-29 minutes
included
99374 – Physician supervising home health
99377 – Physician supervising hospice
Care Plan Oversight (cont.)
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United Healthcare – per Reimbursement
Policy available on UHC website
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Allows for reimbursement of 30 minutes and up
99340 – Physician supervision of home patient
99375 – Physician supervising of home health
99378 – Physician supervising hospice
CARE PLAN OVERSIGHT
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EXAMPLE:
– Newborns under care of Home Health
Agency providing Phototherapy or other
care
– Per CPT, “These codes should not be
reported for supervision of patients…
unless they require recurrent supervision
of therapy.”
CARE PLAN OVERSIGHT FORMAT
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Documenting Care Plan Oversight Services
• Patient Name:_____________________
Home Health Care Agency:______________
• Diagnosis:________________________
Date Service Started:______________
• Physician:________________________
• At end of service per month, add total time for all days and if greater than 15
minutes, can bill for these services.
Month
Adviceservice performedcommunication
Daily Minutes
TOTAL MINUTES
Date
Date
Date
NURSE VISIT
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99211 – Established patient level 1

Recognized by payors as nurse only visit,
except BCBS-AL

BCBS-AL requires physician/provider to be
face-to-face with patient
Developmental Testing Codes
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96110 – Developmental Testing, AAP recommends
standard tools: ASQ, PEDS, M-CHAT, Denver, etc
Payor Specific: Add Modifier 25 to E/M or Mod 59 to
96110
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BCBS: Pays with and without Mod 25 currently
MCD: Not currently required
Commercial payors: check policies
V79.3 – Screening for Developmental Handicaps
–
Recognized by All-Kids and Medicaid for payment
96110 – Developmental Screening
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ALL-KIDS allows 96110, limited to 4
screenings by age 48 months
Medicaid allows any age
BCBS-AL allows code 96110 but
diagnosis and contract determine
payment by BC/generally can bill
responsible party
INJECTION ADMINISTRATION
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96372 – Therapeutic and Diagnostic Injection
–
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Re-numbered code 2009
Requires Modifier 25 attached to E/M code
MODIFIERS
MODIFIER 24
 Unrelated E/M Service by Same Physician
(Group) during Postoperative Period (Global
Days)
 Patient returns after treatment of fracture
within 90 days for sore throat
 99213-24 Office Visit with Pharyngitis
462
MODIFIER 25 and 59

Modifier 25: Shows service or procedure
significantly separate from E/M service

Modifier 59: Shows procedure or service distinct or
independent “from other non-E/M service performed
on the same day…”
— Resource for all Modifiers: CPT Appendix A
MODIFIER 90 & 91

Modifier 90: Attach to lab test when sent to
an outside laboratory

Modifier 91: Attach to the second lab test
when a repeat test is performed to confirm
findings (not for technical error)
NCCI
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National Correct Coding Initiative
Website for NCCI edits
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Comprehensive Column 1, Component Column 2
Mutually Exclusive
One in Modifier column indicates modifier allowed
http://www.cms.hhs.gov/NationalCorrectCodInitEd
/NCCIEP/list.asp#TopOfPage
NCCI MODIFIER EXAMPLE
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94640 – Inhalation Treatment
94664-59 – Demonstration and education of
nebulizer, MDI, etc.
NCCI shows 94664 as a component (Column
2) of 94640 (Column 1) therefore modifier 59
is required on the component code.
NCCI and PAYORS
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Some payors follow NCCI completely and
some follow NCCI partially.
United Healthcare has adopted NCCI policy
Medicaid follows NCCI with the exception of
EP modified codes
BCBS-AL partially follows
REAL-TIME CLAIMS ESTIMATOR
Preventive Care with
Sick and Mod 25
AETNA CLAIM CHECK
Preventive Care with Sick
without adding Mod 25
APPEAL
Appeal process simplified with
standard letter for common denials

–Modifier
25
–Medical necessity
Payors automatically edit first claim but
60% of claims will be paid on appeal
historically
 Appeal online through payor website

QUESTIONS?
WEBSITE RESOURCES

Search any payor name and almost all have a website now with claim
status/Eligibility & Benefits, Claim Status, some with Real-Time Claims
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INSURANCE PAYOR LIST FOR ELECTRONIC #
http://direct.medifax.com/payerlist.asp?page=1
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BCBS-AL
https://www.bcbsal.org/providers/
AL MEDICAID
http://www.medicaid.alabama.gov/billing/
UNITED HEALTHCARE
https://www.unitedhealthcareonline.com
VIVA HEALTH INSURANCE
http://www.vivahealth.com/
Web Resources
http://practice.aap.org/ AAP Members Only
Practice Management Online
Contains:
Updated RBRVS brochure
Carrier appeal letters
Private Payer Advocacy Monthly Update
Vaccine Financing Resources
Carrier Take-back information