By Dr. Sue Kressly
Well visits are becoming increasingly complex as the Bright Futures periodicity schedule changes. Over the past few years, evidence informed guidelines suggest additional items be performed as part of a comprehensive visit. It is important to make sure you are using the correct CPT codes in order to receive appropriate payment.
In addition, as more insurance companies are auditing pediatricians, you want to make sure you are choosing the most appropriate CPT code for the work you are doing. This includes services you have provided for years, as well as services which you are adding. There have been cases of pediatricians losing their practice and paying back significant monies when they, for example, used inappropriate urinalysis and hearing screening codes. (Click here to read about a prominent pediatrician from TN where this happened.)
If you have “always” used a particular CPT code for hearing and vision screening, or developmental testing, it is still your responsibility to review the codes you are using and make sure they are representative of the work you perform. The AAP has a great resource on coding for well visits that discusses many of the common CPT codes used by pediatricians.
Some common mistakes pediatricians make that you want to avoid
Developmental screening: You should be using 96110 not 96111 routinely. According to the
AAP Developmental screening resources: “In 2012, the 96110 code descriptor was revised to differentiate it from the “testing” that is referenced under code 96111. Screening asks a child’s observer to provide his/her observations of the child’s skills, which are then recorded on a standardized and validated screening instrument. Screening is subjective and only reports the assessment of the patient’s skills through observation by the informal observer. On the other hand, testing measures what the patient is actually able to do on a standardized psychometric instrument at that time. Screening does not imply a diagnosis; only the means by which information is collected on the patient.”
Tools for which you should be using the 96110 include ASQ, PEDS, M-CHAT, SWYC and others.
96111 should not be used for routine screening of all children. 96111 should be used if you identify a child who is not developing normally and do a more thorough in-office testing such as: Bayley Scales of Infant Development, Woodcock‐Johnson Tests of Cognitive Abilities (Third Edition) and Clinical Evaluation of Language Fundamentals (Fourth Edition).
Vision Screening: The most common codes used by pediatricians are the following: 99173 “Screening test of visual acuity, quantitative, bilateral”, and is used if you do vision screening using a Snellen Chart, Titmus screener or other instrument to get quantitative results such as 20/20. 99174 Instrument-based ocular screening (e.g. photoscreening, automated-refraction), bilateral, with remote analysis and report.
Code 99177 is reported in lieu of 99174 when the screening instrument provides you with immediate pass or fail results. 92081 should not be used routinely by pediatricians as part of screening. This code is used for complete visual field testing and is most typically performed by an ophthalmologist.
Hearing Screening: 92551 “Screening test, pure tone, air only” and 92552 “Pure tone audiometry (threshold), air only” are the most commonly used hearing screen codes used by pediatricians. What’s the difference? For 92551, the tester sets the machine at a constant intensity (threshold) while playing various frequency tones in each ear. The volume is the same and the pitch varies. For 92552, the machine not only changes tones in frequency, but also changes intensity. The tester records the very lowest intensity a person can hear at various frequency levels.
Not sure which test your staff is doing? Ask them and make sure you are using the correct CPT code. For the most part, pediatricians are not performing 92556 “Speech audiometry threshold with speech recognition”. That testing would require you to have complex evaluation tools where the tester speaks a word into a machine, the machine determines its intensity, and the patient repeats the word being spoken. Also be careful to use the correct CPT if you are using an Otoacoustic Emissions (OAE) device.
If you are audited and you are using the wrong code, you can be subject to take backs and fines. As a physician, it’s your responsibility to know that you are using the correct codes for the work being done in your office. It’s not the job of the biller or the office manager. It’s the job of the provider whose name is on the claim. Just because you can get paid better for a different CPT code, doesn’t mean you should use it. You risk significant amounts of penalty monies, and in some cases, your professional livelihood.
Take the time now to review your CPT codes for procedures being done at well visits and use the AAP resource mentioned above. Then, when you are sure you are billing correctly, do the same thing for the rest of your commonly used procedures. Code with confidence and get paid for what you do.