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How to avoid nonpayment pitfalls for a variety of unconventional services.
Pediatric coders are often caught, between doctors who don't want to impose a fee on a patient and an accounts receivable ledger that keeps them up at night. Before you write anything off, first find out if you can bill the parent.
The classic payment crisis scenario in pediatrics is the noncovered service, such as attention deficit disorder with hyperactivity (ADHD). Denials due to noncoverage should almost always be turned around and billed to the parent, billing experts say.
For example, the pediatrician sees a patient for ADHD, billing 99213 based on time, and lists ADHD (314.01) as the diagnosis. The insurance company denies the claim saying it's excluded from benefits due to the diagnosis. "In many cases, ADHD is a noncovered service," says Carol Edgerly, CPC, coder for Cle Elum Medical Center in Cle Elum, Wash. (4 physicians, 1 PA). "We do not normally write these off."
Denials due to "bundling" often have to be written off, says Edgerly. Denials due to deductible or copay requirements cannot be written off; the patient's portion must, by insurance contractual requirement, be billed to the patient.
Well and sick visits
A typical example of bundling is the well visit (9938x, 9939x) and the sick visit (99213, for example) with modifier -25, and a diagnosis code for the condition linked to 99213. While some companies pay for this combination (notably Aetna, see PCPS 7/05, 12/05), most deny it as bundled, paying only the well visit. You can't bill the patient for the sick part of the visit, because that E/M, with that ICD-9, is normally covered by the policy.
"We don't even bill both the well and sick visit," says Nelda Laskey, RHIT, coder for Siena Medical Clinic at St. Catherine's Hospital in Garden City, Kan. "Blue Cross just says, 'We pay for one but not for both,' and we'd have to write the sick visit off anyway," she says. Instead of creating an accounting problem with the write-offs, it's easier just not to bill this combination, she says. "But we do put both diagnoses on the well visit, with the secondary diagnosis being whatever the minor problem was that came up."
But don't be too hasty to write off-or not bill-the sick portion of a well-sick visit combination. "If there is adequate documentation of the sick portion, you could appeal it and they would probably pay it," says Edgerly. "You don't have to bill the patient if the insurance company denied the sick part as a bundled service. But I always appeal these if there's documentation. If it wasn't documented adequately, it shouldn't have been billed at all." If you shouldn't have billed it in the first place, it should be credited, as opposed to written off to charity or an insurance denial, says Edgerly.