Developmental Screening Billing and Payment

Developmental Screening
Billing and Payment: Stories from the
Front Line
Michelle M. Macias, MD
D-PIP Workshop 2
September 7, 2007
I have no relevant financial relationships with the manufacturer(s) of any commercial product(s)
and/or provider of commercial services discussed in this CME activity.
Importance of Accurate Coding
 Improved
Information Processing
– Accurate diagnostic coding requires analyzing all provided
information (subjective and objective)
 Decreased
– Documentation
– Compliance
 Increased
– One minute of extra work can result in an increased code
The Codes: ICD-9-CM and CPT
 ICD-9-CM:
International Classification of Diseases,
Ninth Revision, Clinical Modification
– Why the service was done
– Information collected by payers to manage risk
(preexisting conditions; refused diagnoses)
 CPT:
Current Procedural Terminology
– What was done
– Provides the basis for payment
ICD-9-CM and CPT
 Your
financial success –or failure can be
directly related to proper coding for both the
diagnosis and the service(s)
 The ICD-9-CM and CPT numbers MUST be
used on the claims sheet – not written
diagnostic descriptions
– Claims denied, fines or penalties levied, even
imposed sanctions!
 Physicians’
Current Procedural Terminology (CPT)
codes for services are always reported to payers with
diagnosis codes from International Classification of
Diseases -9th edition, Clinical Modification (ICD-9CM)
 Important point: The Health Insurance Portability
and Accountability (HIPAA) Act of 1996 requires
payers and physicians to use ICD-9 CM. As revised
ICD-9 CM codes are activated, you must use these
updated codes. Obviously, these codes explain to
payers the specific reason a patient was seen.
 The
reason for the service (visit)
 The first diagnostic code reflects the condition the
professional is actively managing:
– “the reason for the visit”
 Subsequently
listed codes
– Factors important to condition #1
– Coexisting conditions tx. and management of #1
 If
a child is seen for a residual condition (e.g.
hearing deficit), code this first with the cause of the
condition as a secondary ICD-9-CM code (e.g.
“The Top→Down View”
Code to the highest degree of specificity
Code to the highest degree of certainty for the encounter
such as symptoms, signs, abnormal test results
Probable, suspected, questionable, or rule out should not be
List the ICD-9-CM code that is identified as the main reason
for the service first, then list co-existing conditions
Chronic disease treated on an ongoing basis may be coded
Do not code for conditions previously tx that no longer exist
 Do
code only the conditions/problems you are
actively managing at the time of the visit and
diagnoses affecting the current status of the child
 Do not code for previously treated conditions
 May include conditions existing at the time of the
patient’s initial contact as well as conditions
developing subsequently affecting treatment
 Dx. relating to a pt.’s previous medical problems w/
no bearing on the present condition are not coded.
 Do
not code dx. listed as “rule out,”
“probable” or “suspected” –they are not
established in out-patient practice
 Do code to the highest degree of certainty
 Do not code symptoms if a dx. has been
made: Eg.: If a child with ADHD is seen for
routine med. monitoring and headaches are
reported w/ meds.: code 314.01 first, then
headache as #2.
a code has 5 digits, you must code to that 5th
 Do not arbitrarily use a zero as a filler character
when writing an ICD-9-CM code
 If
– The addition of a zero to a code number not requiring an
additional digit can cause a claim denial
 Fourth
position numbers .8 (NEC: other specified)
and .9 (NOS: unspecified) are usually ‘residual
Developmental Examples
Delayed milestones
Language disorder, developmental
Learning disorder, NOS
Static encephalopathy
Lack of coordination
Impairment of the ability to perform smoothly coordinated voluntary
movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and
other structures. Loss of muscle coordination.
781.3 is a specific code that can be used to specify a diagnosis
781.3 contains 25 index entries, including dysdiadochokinesis, ataxia NOS,
hypotonia, hypertonia
Useful websites:
 The ICD-9-CM is maintained jointly by the
National Center for Health Statistics (NCHS) and the Centers for Medicare &
Medicaid Services (CMS).
 Residual
– NEC: Not elsewhere classifiable: conditions
specifically named in the medical record but not
specifically listed under a code description
– NOS: Not otherwise specified: a diagnostic
statement lacking detail in describing a specific
condition (e.g. 314.9 unspecified hyperkinetic
 Code
the diagnosis to the highest level of
certainty (the words in the descriptor)
 Code
the diagnosis to the highest level of
specificity (the numbers in the descriptor)
 Remember,
a chronic condition (e.g. delayed
development) managed on an ongoing basis
may be coded and reported as many times as
applicable to the patient’s treatment.
 The level of the E/M visit may change as the
complexity of the child’s needs change.
V Codes
 Are
used to deal with occasions when circumstances
other than a disease or injury are recorded as
“diagnoses” or “problems”
– When a pt. who is not currently sick, encounters a health
provider for some specific service (e.g. weight check)
– When a pt. presents for a specific tx. of a known
condition or disease
– When a pt.’s health status is influenced by some
circumstance which is not in itself a current injury or
illness (e.g. parental hx of alcoholism)
V Codes
codes may be sequenced in the first position if
the pt. was not seen for an active illness/injury
 Be cautious when using V codes as 2nd or 3rd
diagnoses because, as Medicare automatically denies
these claims, many other payers who adopt
Medicare policies may also deny the claim
– Note: This may be especially true for clinics located in
facilities who primarily serve adults –they adopt CMS
policies rather than CPT
DB ‘V Codes’
Problems with learning
Problems with communication (including speech)
Mental and behavioral problems; other behavioral problems
Unspecified mental or behavioral problem
Lack of housing
Inadequate housing
Inadequate material resources
Other specified housing or economic circumstances
Counseling for parent-child problem, unspecified
Parent-child problems; other
Health problems with family; other
Health problems within family; other specified family circumstances
Health problems within family; unspecified family circumstances
Other psychosocial circumstances; unemployment
Other psychosocial circumstances; legal circumstances
Interpersonal problems, NEC
Bereavement, uncomplicated
Other psychological or physical stress, NEC; other
Unspecified psychosocial circumstance
Other specified counseling
Observation for suspected mental condition; childhood or adolescent antisocial behavior
Special screening for thyroid disorders
Special screening for mental retardation
Special screening for developmental delays in childhood
Unspecified mental disorder and developmental handicap
Special screening for neurologic condition
Special screening for lead poisoning
Current Procedural Terminology
 Published
 Listing
by the AMA
of the codes and descriptions for
procedures, services and supplies
 Used
to bill insurance carriers
CPT Coding
5 Basic Principles of Use
 Practitioner
should select diagnosis and procedure
 Document patient’s services to support codes
 Use separate codes for different encounters
 Learn to use modifiers, testing and add-on codes
 Design a superbill/computerized routing sheet
“RVU Review”
 Resource
Based Relative Value Scale (RBRVS)
 Relative Value Units (RVUs): “The Coin of the
 A numerical value (relative reimbursement) assigned
to a CPT code
 Calculated on
Amount of physician work
Practice expenses
Malpractice cost
Service location (office vs. hospital)
RVU Components of Physician Work
 Pre-,
intra-, post- service work
Time to perform the service
Technical skill and physical effort
Mental skill and judgment
Psychological stress associated with iatrogenic
Developmental Screening
 96110:
Developmental testing, limited
– Aka Developmental screening, with interpretation and report
– Expectation is that the screening tool will be completed by a
non-physician staff member and reviewed by the physician
– No physician work is included in the RVU
– Reported in addition to E/M services provided on same date,
with modifier (-25)
– Report for each screen administered
– Medicaid may not pay separately for developmental screening
when provided as part of Early and Periodic Screening,
Diagnostic, and Treatment services (EPSDT)
Developmental Testing
 96111:
Developmental testing-extended
– Used for extended developmental testing/evaluation
typically provided by the medical provider
– Used when ‘hands-on’ testing is completed
– Includes the interpretation and report
– Based on 1 hr of physician work (2.6 Work RVU)
– Reported in addition to E/M services provided on
same date, with modifier -25
 Services
altered by specific circumstance
Tells insurer “this visit is different”
-21 Prolonged E/M Service
-25 Significant separately identifiable E/M service by the
same physician on the same day
Used to report developmental screening/testing with E/M
-32 Mandated Services
-52 Reduced Services
Billing Stories: Challenges arising from
inconsistent reimbursement policies
“What we decided to do…was we brought the
cost of the 96110 code down to something that
was very nominal: five dollars….We have this
rule that if the balance on the account is less
than ten dollars it gets written off. So when it
was five dollars they got written off.”
“The person for billing didn’t want us to bill for
[developmental screening] because then the
whole thing gets denied so we would have a lot
of non-payment…she just advised us to not
even circle it so we didn’t have problems
from the billing standpoint if it wasn’t going to
get paid for.”
Billing Stories
“ My director said that [insurance carriers] will
come back and say why them, why not everyone
else? …everyone else may have to pay for it but
your [Medicaid] patients don’t, so why is there a
discrepancy? So we couldn’t bill for
[developmental screening].” (Bottom line from
their billing standpoint: if going to charge, have to
charge everyone…if you can’t do that, don’t
charge anyone)
The billing service set the fee (~$110) for 96110. It
wasn’t reimbursed so the fee got passed on to
the patient without review by the provider.
Providers were mortified.
Billing Stories: 96110 & 96111
 Same
carrier (depending on the plan):
– Bundled 96110 and did not pay separate fee
– 96110 was covered and fee paid
– 96110 not allowed and fee passed on to patient
 96110
vs 96111
– 96111 involves physician work (RVUs) and paid
for, but 96110 wasn’t paid
– Practice chose to bill 96111
Billing Stories: 30 month visit
 Practices
assumed 30 month visit
wouldn’t be paid for, so didn’t call
insurance company
– If appealed, some would get visits
– Some practices were advised by coders to
‘give it up’. Basically, billing was more
trouble than it was worth as they would
ultimately have to reverse the charges