Managing Payor Denials related to Supplemental CPT Codes associated with Well Visits at Pediatric Practices

The use of scoring tools in Pediatrics helps the Pediatrician or Pediatric provider in making a more informed assessment of the child.    While using a scoring tool is extra work for the pediatric provider, in many cases, the payer will reimburse for the associated scoring tools CPT codes when utilized for appropriate pediatric patient visits.    Pediatric practices leverage scoring tools such as Ages and Stages, the Survey for Well Being of Young Children (SWYC), MCHAT, Connors or Vanderbilt for ADHD, Maternal Depression Screening tool and Adolescent Depression screening tool.    The PediatricXpress system by Physician Xpress, Inc. has some of these common Pediatric Practice scoring tools incorporated into the system.   Additionally, Pediatric practices can scan in additional completed scoring tools or work with Chadis to leverage their integrated platform and support.      When using these scoring tools as part of the clinical workflow of the practice, it is important that the billing team is aware of the scoring tools leveraged by the practice so as to ensure the billing is optimized appropriately.    Medical billing related to the scoring tools includes adding the correct CPT code associated with the scoring tools in addition to the well or sick visit code.   Additionally, the Pediatric practice should document the use of the scoring tool in the patient chart (if a paper scoring tool is used, it should be scanned into the chart of the patient).  Note that some payers will be more challenging than others and might deny these CPT codes which can be appealed.     

At least one of the national payors denies some of the scoring tools CPT codes and requests documentation that a scoring tool was utilized during the visit.  When a denial occurs, the medical billing team should appeal the denial by providing the information in the medical record that aligns to this scoring tool code.   For instance, if the scoring tool used is SWYC as a developmental scoring tool, and the associated CPT code sent to the payer is 96110, the payer could deny or question this code.    In this case, the biller should obtain a copy of the completed SWYC for this visit (the completed scoring tool should be scanned in the patient’s chart for the associated visit so the biller can access the information) and sent to the payer for appeal of the denial.  The pediatric practice benefits when the billing team has a good understanding of the scoring tools utilized.  Follow-up on denials by the billing team helps increase revenue for Pediatric practices.    Follow-up on a denial usually requires a copy of the chart documentation showing the completed scoring tool to appeal to the payer for reimbursement to the practice.   While there are coverage differences related to Pediatric Scoring tools by payers, a Pediatric Billing team should be following up on denials with documentation from the Medical Record so the Pediatric practice can receive reimbursement for their services.   Many billing teams and billing companies have inconsistencies and gaps in their follow-up on denied claims.     The Physician Xpress billing team has people, processes and procedures to optimize the revenue cycle for Pediatric practices.