Coding and Reimbursement
for CSHCN
KEY TO SOLVING REIMBURSEMENT
PROBLEMS
This section provides an overview of coding and reimbursement
issues related to caring for children with special health
care needs. Included are coding resources as well as key
points for addressing reimbursement problems.
SERVICE > CODE
> VALUE > RBRVS
> FEE SCHEDULE
> CONTRACT > $
The Challenge:
Improve coding skills to increase the financial health of
your practice
How to start:
Begin the use of office tools that improve documentation/coding
of CSHCN encounters
The Opportunities:
- Use Higher Level E/M codes
- Use Procedure Codes
- Be a Consultant
- "Max-Pack" Visits: Well Plus Sick Care with
-25 Modifier
- Bill for "Non Face to Face" Care
- Provide Group visits
Care Plan Oversight Codes
The new care plan oversight codes are intended
to report care plan oversight services of children with
special health care needs and chronic medical conditions
provided by primary care physicians who coordinate the medical
care management with other medical and non-medical service
providers and family. The codes may encompass oversight
of work or school programs the patient may be attending
where therapy is provided.
- 99339 Individual physician supervision
of a patient (patient not present) in home, domiciliary
or rest home (e.g., assisted living facility) requiring
complex and multidisciplinary care modalities involving
regular physician development and/or revision of care
plans, review of subsequent reports of patient status,
review of related laboratory and other studies, communication
(including telephone calls) for purposes of assessment
or care decisions with health care professional(s), family
member(s), surrogate decision maker(s) (e.g., legal guardian)
and/or key caregiver(s) involved in patient's care, integration
of new information into the medical treatment plan and/or
adjustment of medical therapy, within a calendar month;
15-29 minutes.
- 99340 30 minutes or more (Do not report
99339, 99340 for patients under the care of a home health
agency, enrolled in a hospice program or for nursing facility
residents.)
View the
Article on the new codes in AAP News, November 2005.
For more information, contact the AAP Division of Health
Care Finance and Quality Improvement at dhcfqi@aap.org.
Index
of CPT Codes for Medical Home
The Pennsylvania Chapter of the American Academy of Family
Physicians (AAFP) recently modified the "Crosswalk
to Reimbursement " which identifies the range of relevant
codes that could be used to finance components of a medical
home. To view the modified document "Index
of CPT Codes for Medical Home," click
here 
The 2003 Crosswalk
includes selected vignettes and was developed by Margaret
McManus, Alan Kohrt, Joel Bradley, and Linda Walsh in collaboration
with the Center for Medical Home Improvement, the American
Academy of Pediatrics, and the National Institute for Children’s
Healthcare Quality.
AAFP Coding Specialist Cindy Hughes, CPC, updated this coding
information to reflect 2006 CPT coding changes. In 2006,
confirmatory consultations are deleted, new codes are added
for care plan oversight of a patient who lives at home or
in a non-medical facility such as an assisted living facility
and who is not in home health or hospice, and all codes
for emergency or after-hours services were changed. One
of the original authors, Linda Walsh, Manager of the Committee
on Coding and Nomenclature and Director of the Division
of Health Care Finance & Quality Improvement at American
Academy of Pediatrics.
The PA-AAFP also developed a
medical home web page on coding and resources that includes:
- Financing the medical home
- Strategies
- Issues for dual-eligibles
- Code breakdown
- Sources
- Resources
Tools for the office
Developmental Screening/Testing Coding
Fact Sheet
Developmental screening, surveillance, and assessment are
often complemented by the use of special tests, which vary
in length. This Coding Fact Sheet provides guidance on how
pediatricians can appropriately report limited and extended
developmental screening and testing services. Developed
by Committee on Coding and Nomenclature and the Section
on Developmental and Behavioral Pediatrics.
- Coding
Conundrums Spring 2005: How to Adapt Physician-Administered
Developmental, Behavioral and Emotional Screening to CPT
Codes 96110 and 96111
2006 Care Coordination Toolkit
WHAT's NEW: includes vignettes for the new care plan oversight codes, information on non-physician care coordination provider codes.
Description: Proper Use of Coordination of Care Codes with Children
with Special Health Care Needs (CSHCN). This toolkit provides
information on billing for the coordination of care with
descriptions of individual codes, proper documentation,
and an easy to follow billing slip for physician and non-physician time. Developed by the Center
for Infants and Children with Special Needs at
Cincinnati Children’s Hospital Medical Center
& The National Center of Medical Home Initiatives for
Children with Special Needs.
Appendices Included:
- Identification of CYSHCN: Tools and Strategies
How to Label / Flag the Chart: Tools and Strategies
- Forms
- How to Negotiate with Public and Private Insurers:
Tools and Strategies
- Selected Vignettes
Forms from the toolkit are available
in word and excel formats
Documentation Guidelines
for New Patients
This document provides the documentation guidelines that
support the reporting of office or other outpatient services
provided to new patients.
Documentation
Guidelines for Initial Consultations
This document provides the documentation guidelines that
support the reporting of initial consultations for new or
established patients.
Levels of History
This document outlines the levels of history as found within
the documentation guidelines. Further, it compares CPT versus
Medicare requirements for history of present illness, review
of systems, and past/family/social history.
99214 and 99215 Key Elements
Coding Resources
AAP Coding, Documentation, and
Reimbursement in Pediatric Practice Workshops
Presentations on Coding and Financing
for CSHCN 
SURVIVOR®:
Successfully Financing a Medical Home
Presented at the CATCH and Medical Home National
Conference in July, 2004.
(1.55 MB)
Joel Bradley, MD, FAAP
Pediatrician, AAP CPT Advisor
Lois Kohrt
Director of Practice Management, Children's Hospital of
Philadelphia
Coding for children with special health care needs
Prepared by James C Ledbetter MD FAAP, Medical
Consultant,CDPHE
Section on CYSHCN
Overview
1. Defining Medical Home and CSHCN
2. Codes, Fees, and Reimbursement
3. CSHCN Encounters: Understanding Evaluation and Management
(E/M) Codes
Examining Costs and Child Health Outcomes Related
to the Provision of Medical Homes for CYSHCN
Presented at the CATCH and Medical Home
National Conference in July, 2004.
Richard
Antonelli, MD, MS, FAAP+ (274 KB)
Nashaway Pediatrics
Overview
1. National Study of Care Coordination Measurement
in Medical Homes
2. Implications for Policy or Practice
Elizabeth
Shenkman, PhD (322 KB)
Associate Professor of Pediatrics and Health Policy and
Epidemiology
College of Medicine, University of Florida
Overview
1. Comprehensive Financing Strategies for CSHCN
2. Characteristics of CSHCN
3. Assessment of currently used state strategies
4. Quality of care and financing
David
Lee Wood, MD, MPH, FAAP* (206 KB)
Associate Professor of Pediatrics
Chief, Division of Community Pediatrics
University of Florida & Duval County Health Department
Overview
1. Impact of a Medical Home on Financial Burden
to Families with CSHCN
2. Medical Home Study that involved 3 intervention and
3 control practices
Intervention:
-Placed Title V care coordinator into offices
-Active CQI program to implement “Medical Home”
-Measurement/feedback to practices on Medical Home Index
-Control practices received standard of care
Medical
Home Crosswalk to Reimbursement
Peggy McManus
MCH Policy Research Center
Washington, D.C.
Presented at The Pediatricians’ Title V CSHCN in May,
2003
www.mchpolicy.org
Overview
1. Present insurance findings from National Survey
of CSHCN.
2. Review medical home care model.
3. Present reimbursement crosswalk.
4. Discuss sample vignette.
5. Build the case for insurers.
Handouts
The Crosswalk to Reimbursement: This reimbursement
tool identifies the range of relevant codes that could
be used to finance components of a medical home and contains
an index of medical home codes and selected vignettes.
“DATA
to DOLLARS”
Lois Kohrt
Director of Practice Management, Children's Hospital of
Philadelphia
Presented at The Pediatricians’
Title V CSHCN in May, 2003
Overview
1. Coding/Documentation
2. Getting Paid (or not)
3. Office Teams
4. Data
5. What to collect
6. How to collect it
7. What to do with data collected
Shared
Responsibilities Toolkit: Tools for Building Partnerships
to Improve Health Care Financing for CSHCN
Susan G. Epstein
New England SERVE
Presented at The Pediatricians’
Title V CSHCN in May, 2003
Overview
1. Get attention of health plans
2. Identify CSHCN as a population (15%)
3. Make a business case for investing in QI
4. Provide tools/resources to improve systems of care
for CSHCN
5. Promote partnerships & collaboration
(Title V, families, physicians, health plans)
Handouts
Click
here to download the Shared Responsibilities Toolkit
In The News
Reimbursement Code Could Increase Online Consultations (iHealthBeat,
12/22/03)
The American
Medical Association on Jan. 1 will establish a reimbursement
code for online communication between a physician and patient,
making it easier for doctors to receive payment from insurers
for online visits, the Associated Press reports. However,
each insurer will still decide whether to pay for e-mail
consultations, an AMA spokesman said.
Doctors have been unwilling to communicate online with patients
because most health plans won't cover it, according to Monique
Levy, a health care analyst at Jupiter.
Doctors also worry about the potential legal liability of
treating a patient online rather than in person. A recent
Jupiter survey found that only 9% of U.S. doctors e-mail
their patients more than five times a week, and these online
visits are usually for appointment scheduling or billing
questions. Only a few plans, such as Blue
Shield of California and Blue
Cross and Blue Shield of Massachusetts cover online
visits.
Levy predicted that online consultations will become a cheaper
and easier way to receive care, particularly for chronic
patients who need constant monitoring. Several companies,
including MyDocOnline
and RelayHealth,
already provide software for online visits.
Kirk Schueler, CEO of MyDocOnline, said that online consultations
could improve doctor-patient communication and improve follow-up
care for chronic patients. Eric Zimmerman, senior vice president
at RelayHealth, said researchers from the University of
California-Berkeley and Stanford University found that online
visits improved satisfaction and lowered costs (Koenig,
Associated Press, 12/18).
Last Updated
March 18, 2008
