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How to negotiate esoteric E/M codes when billing for the care of special needs patients.
Pediatricians who know their way around the more esoteric E/M codes can find that, while they won't get rich treating any special needs patients, there is adequate reimbursement for the extra work involved. Many doctors who assume primary care responsibilities for these patients-those with Down's syndrome, for example-often do so for the personal fulfillment it gives them. The family is also very appreciative. But some pediatricians have been pleasantly surprised to find gratification from an unexpected arena: payers. The fact is that insurance companies appreciate primary care pediatricians for serving as the "case manager," supervising and directing care. It helps them avoid paying expensive consultation fees to other providers.
Three key coding rules
You need to keep three coding rules in mind for special needs: Report the diagnosis code for the most serious condition diagnosis in almost all cases; track and bill for all extra face-to-face time spent with the patient; and track and bill for care plan oversight and case management activities.
Here's another tip: Be prepared early on to negotiate with the payer for extra fees for these children. Time spent up front will pay off in the long run, because of the chronic nature of the problems these children have.
Let's look at each of the three coding rules.
Special needs patients will always have serious chronic diagnoses that will command the respect of the claims representative. The patient's serious diagnosis will already be known to the insurance company, but if it figures into the work done during an encounter, it also justifies a higher level E/M.
Rappo recommends using the chronic diagnosis every time a special needs child is seen-not just to get paid, but because these diagnoses impact virtually everything you do.
For example, a patient with juvenile rheumatoid arthritis (JRA) (714.3x) comes in with an earache. The pediatrician diagnoses otitis media (381.0x). But the mother also wants to talk about the child's medication and other issues related to the JRA.
Use 381.0x as the primary diagnosis, because the patient came to see the doctor due to the earache. But put 714.3 as the secondary diagnosis because this visit is a lot more than a 99213 earache visit, says Rappo.
Sometimes the diagnosis code won't be readily apparent.
There are some patients who will be special needs, but won't have a specific diagnosis that explains why. For example, very early premature babies are likely to have a host of problems, including asthma, retinopathy, re flux, and developmental delays. Some may still have a feeding tube.
You would use the prematurity diagnosis, at least in the early months of the child's life. Later, however, you may use other diagnoses instead. But even if you can no longer report prematurity, the child would still be considered "special needs" clinically, because of the sequelae of prematurity.
For example, asthma by itself would not be considered special needs, but because the child was premature, it presents greater health problems. As the child gets older, the prematurity diagnosis will no longer be used, but the child may still have health problems related to this.
Because the ICD-9 code won't always be the same, it's important to negotiate early with the payer to make sure you will be reimbursed for monitoring these children. You want to make sure that when you stop using the prematurity diagnosis, the payer still recognizes that this patient has special needs.