Uncircled vaccines, administrations could cost your practice 10%.
Think increasing payments in 2010 is a fairy tale? Your magic wand is right at your front desk.
“Check-out coding can have a significant financial impact,” reported Norman “Chip” Harbaugh, MD, in “Vaccine Reimbursement — Quite a Quandary” at The Coding Institute’s December 2010 Pediatric Coding and Reimbursement Conference in Orlando. Not having the check-out person make sure the pediatrician circles all performed services and procedures can cost a practice with median collections of $556,000 between 2.2 percent to 10.2 percent or $12,340 to $57,000.
To shore up those payment holes, train your front desk staff to spot two signs of overlooked coding opportunities.
#1:Verify 90476-90749, 90465-90474 on Crying Departees
If you have a well child age two or younger who comes to the check-out window crying, there’s a good chance he’s just received his needed shots. The pediatrician may have circled the appropriate preventive medicine service code — 99381 (Initial comprehensive preventive medicine evaluation and management of an individual … infant [age younger than 1 year]) or 99382 (… early childhood [age 1 through 4 years]) for new patients or 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual … infant [age younger than 1 year])or 99392 (… early childhood [age 1 through 4 years]) for established patients. She, however, may have forgotten to code the vaccines (90476-90749, Vaccines, Toxoids) or the administrations (90465-+90474, Immunization Administration for Vaccines, Toxoids). “Our coder has been reporting only the vaccines without the administration,” one physician conference attendee reported.
Tip: “The more eyes you have watching the charge ticket and entry, the more likely you are to avoid missed codes,” Harbaugh pointed out. On a less than two years of age well visit check-out in which the toddler is crying, you can train your check-out staff to ask, “How did the vaccines go?”
Let’s say the mother responds, “No, Suzie didn’t receive any vaccines.” The checkout person knows, “OK, 99381, 99382, 99391, or 99392 as the only CPT code is right,”explains Harbaugh, a primary care pediatrician practicing in Atlanta.
If the mother responds, “Three at one time is so hard,” the check-out person can then check with the nurse or medical technician to find out which vaccines the patient received. On the charge ticket, the check-out person can then add the appropriate administration and vaccine codes.
Example: Suppose the child received MMR, DTaP, and Hib at her 15-month preventive medicine service. The check-out attendant would circle:
For the vaccine products:
- 90707 — Measles, mumps, and rubella virus vaccine (MMR), live, for subcutaneous use
- 90700 — Diphtheria, tetanus toxoids, and acellular pertussis vaccine (DTaP), when administered to individuals younger than 7 years, for intramuscular use
- 90648 — Hemophilus influenza b vaccine (Hib), PRPT conjugate (4 dose schedule), for intramuscular use.
For three shots with physician counseling given to a child less than 8 years of age:
- 90465 — Immunization administration younger than 8 years of age (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) when the physician counsels the patient/family; first injection (single or combination vaccine/toxoid), per day (0.58 relative value units [RVUs])
- +90466 — … each additional injection (single or combination vaccine/toxoid), per day (List separately in addition to code for primary procedure) (0.29 RVUs)
- +90466.
$avings: Catching the vaccines and immunization administrations saves the practice approximately $224. Missing the administrations alone costs you approximately $42 using the 2009 Medicare Physician Fee Schedule and conversion factor (CF) of 36.0666. The breakdown includes $20.92 for the initial administration and $10.46 for each of the two subsequent administrations. Combined with losses of $107.25 for the vaccine products (based on average reimbursements) and $74.28 in capital vaccine investment using Harbaugh’s calculations, you would have had a total loss of $223.53.
#2: Let Your Ears Alert You to Injections
Eavesdropping may not be de rigueur, but you can use overheard conversations to catch missed services. “In the ideal (prepayment) coding process, the doctor checks off the code and diagnosis on the superbill and the staff reviews it and catches any errors,” explains Richard Lander, MD, FAAP, pediatrician with Essex-Morris Pediatric Group in Livingston, N.J.
Let’s say a pediatrician evaluates a patient for croup and the check-out staff heard the physician tell the nurse to give the patient a Decadron shot. The pediatrician didn’t mark “Injection” on the charge ticket. The checkout person checks with the nurse who concurs that the patient received a shot, and the staff then codes the:
- injection administration with 96372 (Therapeutic,prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular)
- drug supply with J1100 (Injection, dexamethasone sodium phosphate, 1 mg).
$avings: Catching that the patient received an injection adds a deserved 0.58 relative value units or approximately $21 to the claim, according to the 2009 Medicare Physician Fee Schedule, which uses a national conversion factor of 36.0666. Most payers adopt this resource-based relative value system in some fashion. The Medicare payment limit for J1100 is $0.09.
@ Pediatric Coding Alert, Editor: Leigh DeLozier, CPC
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