For Professor Ryan

WELL VISIT CODING AND BILLING

FREQUENTLY ASKED QUESTIONS

If you directly pay any portion of your child’s health care costs (co-pay, deductible, HSA, etc), then it is

important to have a general understanding of medical coding and billing. It’s a confusing, boring area but

Kidz1st offers the following explanations and examples to help you understand your potential financial

responsibilities.

What are medical billing codes? Medical billing codes started in the late 1970s and were originally called Healthcare Common Procedure

Coding System (HCPCS) Level 1 codes. In the mid-1990’s, the core set of codes were further expanded

and refined and became known as Current Procedural Terminology, or CPT, codes. CPT codes are a

standardized, numerical coding system that defines every possible service, procedure, test, product, and

device that can be provided in the delivery of health care. The codes fill an 800 page book! A small subset

of CPT codes, called Evaluation and Management, or E/M, codes are used to define office visits.

Why do we need CPT codes? Consistency in the definitions of what is performed, documented, and billed has two purposes:

1) To make sure that there is adequate and consistent payment to health care providers 2) To minimize the chance of fraud by providers and insurance companies.

What do CPT E/M codes tell us? CPT E/M codes tell us what is typically done at office visits or the “typical resources” needed. Resources

include office expenses, provider training/skills/experience, performing the history and physical exam,

decision making complexity and risk, coordination of care, evaluating outside records, counseling, and

time. E/M codes are divided into codes for well visits and codes for acute, chronic, and follow-up visits.

Who determines which CPT codes to use for an office visit? The health care provider who performs the services is ultimately responsible for the accuracy of the codes

billed. Larger offices may employ professional coders. It’s actually a good field to go into! However,

Kidz1st does not delegate this very important responsibility. We believe that the person who actually did

the work, the health care provider, has the best knowledge of what was actually done. So we train our

providers in the gory details of coding. And we do detailed, daily internal auditing so that patients and

insurers alike can be confident that we provide the most accurate coding possible.

Why would I want to know about billing codes? With the country’s economic woes, we are seeing a rapidly spreading trend of employers shifting more

health care expenses, both premiums and direct costs, to employees. Ignorance may be bliss when

someone else is paying the bills but if you are paying, all of this coding information becomes relevant.

So what is included in a “typical” acute visit? For acute, chronic, and follow-up visits, increasing levels of resources required for a “typical” visit are

assigned to increasing “levels” of codes. You will see these codes billed with the numbers 9920x and

9921x, where x is a number 1-5 depending on the level of resources needed. If a lab test or other

procedure is done, that is billed separately because it is NOT “typically” done on everybody.

What’s included in a “typical” well visit? Coding for well visits is much trickier. Well visit codes will be shown as 9938x or 9939x, where x is

again 1-5 but now represents the age of the patient. “Typical” resources needed are fairly consistent from

age to age so CPT E/M codes define a “typical minimum” that must be done. There are, however, two

general scenarios in which “additional” resources are needed and, therefore, coded and billed:

1) When there are “expert recommendations” that certain procedures are necessary as the “standard of care.” There are MANY of these, such as immunizations, developmental

assessment, hearing and visions screening tests, anemia and cholesterol blood tests, and screening

for health and behavior problems. Each of these “recommendations” has their own unique CPT

codes as they require a different set and level of resources. These CAN be predicted ahead of time.

2) When there are “additional concerns” during the well visit NOT “typically” part of a well visit. a. The concern may be expressed by the parent/patient or identified during the visit by the

provider or by screening tests/questionnaires.

b. The concern may be a new problem or follow-up on an existing problem. c. Since the resources required to deal with the concern are similar in nature to those needed

for a separate acute, chronic, and follow-up visits, the acute visit codes 9920x and 9921x

are used.

d. The “-25 modifier” is added to the end of the acute code to show that, while at a well visit, a potential concern was identified that required extra resources.

e. The appropriate “level” of acute code is chosen that matches the amount of additional “resources” required.

f. The modified code is only billed if the concern and the extra work meet certain strict criteria so that this modified code is not misused/overused.

g. Most of the time you CAN NOT predict ahead if a “-25 modifier” code will be used.

Is this new, especially these -25 modifier codes? Codes for various “expert recommendations” have been used for many years. The -25 modifier was

approved in 2007 to recognize the extra resources needed in certain situations. Kidz1st has been using

them since 2009. You may not have previously noticed if your insurance paid the these codes.

So, which of these codes will I be expected to pay and how much? That question is best answered by your health insurance company. Take advantage of the Kidz1st

Insurance Worksheet to help you understand what is covered 100%, what is not covered at all, what has a

co-pay or co-insurance, and what will apply to your deductible.

I called my insurance company and they said these codes should be

included in the well visit code and not billed separately. This process is called “bundling” and, in the above situations, is unethical and potentially illegal.

Bundling is used as an excuse for insurers to not pay what they are contractually obligated to pay. While

there are some CPT codes that supposed to be bundled, none of the above coding examples are included.

If I only knew this ahead of time, I could plan my health care spending

budget better! You are absolutely correct! That is why we created and offered the Kidz1st Insurance Worksheet for your

use. In addition, if we have your email address, we will soon be sending you the expected codes and

charges for your child’s next well visit along with our email reminder of your child’s appointment time

and date. You may also call at any time and ask which codes and charges may be applicable for a visit.

WELL VISIT BILLING AND CODING EXAMPLE SCENARIOS

SCENARIO #1 Jacob comes in for his 4 month well baby visit. Mom has no concerns. History and physical exam reveal

no potential concerns. Mom completes the development and postpartum depression screening

questionnaires which reveal no concerns. Jacob receives his recommended immunizations.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) vaccine and its administration

90670/90460 Prevnar (PCV7) vaccine and its administration

90680/90460 Rotavirus (RV5) vaccine and its administration

SCENARIO #2 Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.

History and physical exam reveal only mild nasal congestion. The provider discusses basic treatment for

the cold. Jacob receives his recommended immunizations. The rest of the visit is as in #1above.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) vaccine and its administration

90670/90460 Prevnar (PCV7) vaccine and its administration

90680/90460 Rotavirus (RV5) vaccine and its administration

99212-25 is NOT billed because the extra resources required did NOT meet the strict

criteria to bill this code

SCENARIO #3 Mom states that Jacob has had an itchy red rash on his face, elbows, and knees for a couple weeks. Mom

expresses no other concerns. Physical exam reveals mild inflammatory eczema affecting the above areas

and is otherwise normal. Jacob is diagnosed with mild eczema. The provider discusses basic skin care

with mom and recommends the use of over the counter moisturizing cream and hydrocortisone cream.

The rest of the visit is as in #1above.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) vaccine and its administration

90670/90460 Prevnar (PCV7) vaccine and its administration

90680/90460 Rotavirus (RV5) vaccine and its administration

99212-25 Acute visit – new problem, OTC medications, followup as needed

SCENARIO #4 Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.

History and physical exam reveal nasal congestion and a right ear infection. The provider discusses the

ear infection, home care, prescribes an antibiotic, and recommends follow-up in 10 days. The rest of the

visit is as in #1above.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration

90670/90460 Prevnar (PCV7) Vaccine and Administration

90680/90460 Rotavirus (RV5) Vaccine and Administration

99213-25 Acute visit – new problem, prescription medication, followup

SCENARIO #5 Mom states that Jacob has mild cough and congestion for 2 days with no fever and no other symptoms.

History and physical exam reveal nasal congestion and a right ear infection. Screening questionnaires

reveal possible developmental delay but no postpartum depression. The provider discusses the ear

infection, prescribes an antibiotic, recommends follow-up in 10 days, and discusses Jacob’s possible

developmental delay. Jacob is referred to Early Intervention for further evaluation. The rest of the visit is

as in #1above.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration

90670/90460 Prevnar (PCV7) Vaccine and Administration

90680/90460 Rotavirus (RV5) Vaccine and Administration

99214-25 Acute visit – multiple new problems, prescription medication,

followup needed, referral recommended

SCENARIO #6 Jacob has a history of congenital hypothyroidism. He is followed by a pediatric endocrinologist. Mom

states that he has been completely well. She has a followup appointment in 1 week but wants the lab tests

done at Crittenton Hospital before the visit. After questioning, mom states that she has missed some doses

of his medication. The provider discusses the importance of consistent treatment, reads the last consultant

report and labs, and writes an order for the next set of labs. Two days later, the provider checks the new

labs and determines that Jacob’s thyroid level is low. The results are faxed to the specialist and the mother

is called to remind her to keep the specialist followup appointment. The rest of the visit is as in #1above.

BILLING CODES

99391 Established patient, well visit 0-11 months old

96110 Developmental screening questionnaire

96110 Postpartum depression screening questionnaire

90698/90460/90461x4 Pentacel (DTaP-IPV-Hib) Vaccine and Administration

90670/90460 Prevnar (PCV7) Vaccine and Administration

90680/90460 Rotavirus (RV5) Vaccine and Administration

99215-25 Chronic Followup visit – followup existing chronic problem,

patient education, lab test ordered, consultant report and labs

reviewed