Medical Home Reimbursement:
Coding and Contract Negotiation for care provided

Children with special health care needs comprise between 10 and 15% of a community-based pediatrician’s practice. Providing better care for a child with a chronic illness requires more time than is typically spent with other children in your practice, more frequent visits, care coordination with other healthcare professionals and with the child's family. There are many potential financial challenges facing the implementation of the medical home in physician practices. This includes accurate and accountable coding for the extended time and services provided to families and children with special health care needs as well as negotiating contracts with payers to receive maximum revenue for the care and services that your practice provides.

Special attention must be directed to scheduling, coding, and documentation in order to maximize reimbursement for the more complex services that may be needed by children with special health care needs and their parents. Not all payers, including the Illinois Department of Healthcare and Family Services (HFS), recognize and reimburse for all the codes that will be discussed in this section. Many office visits for children with special health care needs are routine and require no extra time. Documentation and more precise coding are required to increase practice revenues in those instances when the level of decision-making or planning complexity requires more physician time.

A significant amount of income for your practice comes from successful contracting. Well-negotiated health plan contracts can increase revenue and reduce insurance company hassles by clarifying issues ahead of time. There is a distinct advantage when a practice has at least one partner with good skills in negotiating contracts. It is imperative that physicians carefully review and understand any managed care contract they are considering signing. This is true whether the physician is signing the contract directly or indirectly through a physician network such as an independent practice association (IPA). It is not enough to review a summary of the contract terms. Provisions in the contract that are often glossed over at the time of signing can suddenly spring to life in new and often unpredictable ways when a controversy arises that requires interpretation or clarification. This section will address many of the provisions that require your special attention.

The medical home model offers families of children with special health care needs and physicians a new important opportunity for health care partnership. For the primary care physician the professional rewards of providing medical home services are great, but the financial challenges of the medical home cannot be ignored. Careful attention to contract negotiations with payers and scheduling, coding, and billing procedures can help minimize the primary care physician’s financial barriers to caring for children with special health care needs. Strategies for minimizing these barriers help the physician make “accessible, continuous, comprehensive, family-centered, coordinated, culturally competent and compassionate care” more feasible.

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Coding & Billing for the Care and Services Provided

Scheduling Strategies
Parents of a child with special health care needs appreciate the primary care physician who takes the time to listen, advise, collect data and coordinate care. Most importantly, primary care physicians and families value the opportunity for well childcare with a focus on everyday issues of all children beyond the child’s special needs.

For children with special health care needs, well and sick visits may require considerable amounts of time. Anticipating these visits by scheduling appointments at the end of the day and/or allowing additional time slots for the visit can be helpful to effective practice management.

For example, it may be more appropriate for the child, and a better scheduling option, to schedule a developmental screening apart from a well child visit. The stand alone developmental screening could then be coded as a significant encounter (99214, 99215) reflecting the important medical decision-making, examination and counseling time spent.

The Down-Coding Dilemma
Better reimbursement begins with accurate coding—coding that reflects the unique complexity of children with special health care needs. There are several common reasons when down-coding occurs:

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It is important that physicians accurately identify the procedure code that corresponds to the patient encounter to maximize proper reimbursement. Accurate documentation of the visit will potentially allow the use of higher intensity evaluation and management codes (E/M) that more accurately reflect services provided to children with special health care needs.

For example, a complex sick visit should be billed and coded as 99214 or 99215. By averting down-coding, physicians can increase revenues because of more accurate coding of complex services.

Accurate coding and billing is essential to financially support the philosophy and spirit of the Medical Home: managing and coordinating special health care needs in the context of routine well child care.

Coding Strategies for Well Child Care for the Child with Special Health Care Needs
Often, a child’s special health care needs are addressed in the context of a routine health maintenance visit (99391-99395). It is appropriate to code the routine visit with a modifier –25 (significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

In addition to the well child health maintenance code, you can include the additional appropriate diagnostic code (i.e., hearing loss, hemophilia, cerebral palsy, Down Syndrome). Document the well child visit and problem-focused assessment and management separately. Third party payers will often reimburse both codes for the additional time and work spent on the same visit.

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Coding Strategies for Developmental Screening for the Child with Special Health Care Needs
Developmental screenings may present another coding challenge when providing services to the child with special health care needs. With the understanding that limited developmental screening is an included part of every well child visit, there are instances when developmental screening is more involved and results in subsequent management plans.

For these extensive assessments, use the modifier –25 and link the diagnosis code 783.4x (lack of expected normal physiological development in childhood) to the office visit. The fifth digit (x) is required: use either 783.40 (unspecified), 783.42 (delayed milestones) or 783.43 (short stature). Use of the full intricacies of CPT and ICD-9 coding provides a tool to maximize reimbursement for the Medical Home.

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Assessing Your Practice for Accurate Coding
It is essential that physicians assess billing practices on a continuing basis, which includes the analysis of coding patterns. In Section 3, Reimbursement Strategies, of the booklet Practicing Comprehensive Care Michael Ganz advises evaluating a practice’s use of higher intensity evaluation and management codes by:

Documentation
It is important that a physician supports coding with accurate documentation of the service content of each visit. Identification of the level of service for evaluation and management codes often includes the following variables:

According to Mr. Ganz, “Generally, the documentation guidelines for history taking are more difficult to meet than the guidelines for examination and decision making.” He also advises that using a Pediatric Nurse Practitioner and/or care coordinator to assist with enhanced documentation for higher-level evaluation and management codes may offset staff costs.

Other reimbursement strategies Mr. Ganz suggests for improving reimbursement for services include:

The following information, excerpted from an article by Dr. Aris Sophocles, Coding on the Basis of Time for Physician Services, outlines some of the important parameters to consider when seeking reimbursement for outpatient chronic condition management.

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The “Greater than 50 percent” Rule
It is not unusual to spend a considerable amount of face-to-face time with a patient reviewing problems, adjusting medication dosages, and counseling or coordinating care only to find that you do not have enough history, exam or medical decision-making elements to support a code that would otherwise be appropriate for a visit of that duration. In other words, you’ve spent the time, but the points don’t add up.

This is when the “greater than 50 percent rule” applies. When you devote more than 50 percent of your face-to-face time with the patient for counseling or coordinating care, “time may be considered the key or controlling factor to qualify for a particular level of E/M service,” per CPT.

To code these encounters, use the code that relates to the total time spent with the patient. For example, if you spent 25 minutes face-to-face with an established patient in the office, and more than half of that time was spent counseling the patient or coordinating his or her care, you could use the 99214 code even if you lack the history, exam or medical decision-making elements.

Prolonged Services
The prolonged service codes in CPT are meant to be reported in addition to E/M codes when the length of time a physician spends with a patient goes at least 30 minutes beyond what is typical for that service. When physicians provide services that require more time than what is typical, they can submit prolonged service codes in addition to the appropriate E/M code. When calculating the number of minutes spent in prolonged service, do not include the average time allotted by CPT for that E/M code; count only the minutes spent beyond the typical service.

According to CPT, an example of a prolonged outpatient visit would be the care of an office patient with an acute asthma attack who warrants prolonged face-to-face care by a physician.

CPT also contains two codes for prolonged physician services that are not face-to-face: 99358 and 99359. These are for pre- and post-care services provided in either the outpatient or inpatient setting.

The Care Coordination Toolkit , developed by the Cincinnati Children's Hospital Center for Infants and Children with Special Needs, indicates it is equally important for the managing physician to document all phone calls, care conferences, review of old records, subspecialty letters, test results, etc. as well as the time spent on each. Office staff who interact with the patient, family, other offices, &/or the physician should also document what they do and indicate the time spent discussing and getting direction for the encounter with the managing physician. Thus, a nurse may spend 1 hour on the phone with the family dealing with a new problem and calling in new meds but the office can only bill for the time the nurse spent discussing and being directed by the managing physician which might only be 10 minutes.

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• Case management services:
  • For team conferences lasting approximately 30 minutes, use 99361;
  • For team conferences lasting approximately 60 minutes, use 99362.
• E/M before and/or after patient care (review records/tests, communication with professionals, and/or the patient/family):

  • Use 99358 for the first 60 minutes;
  • Use 99359 for each additional 30 minutes (list separately, in addition to code 99358, for prolonged physician services.)
    
• Care plan oversight:

  • For services relating to a patient residing at home or in an assisted living facility, use:
    99339 for 15 to 29 minutes and
    99340 for 30 minutes or more.
  • For services relating to home care, use:
    99374 for 15 to 29 minutes and
    99375 for 30 minutes or greater.
  • For services relating to nursing facility care, use:
    99379 for 15 to 29 minutes and
    99380 for 30 minutes or more.

At the end of the month, have a staff person collect the logs from the patients' charts, total the time and bill CPO for those patients for whom you provided more than 15 minutes of CPO during the calendar month. Use the start and end dates of the month as the service dates. Finally, return the logs to the charts for use in future months.

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CPO Billing Form
The Care Coordination Toolkit includes suggestions for developing a billing form to help track and manage documentation of services and time. This form should be easily accessible and can be placed in the front of the patient’s chart and all staff involved in the patients care should fill it out but remember it is only for physician time. CPT Guidelines indicate: "The complexity and approximate physician time of the care plan oversight services provided within a 30 day period determine code selection." Note: depending on the diagnosis/ICD-9 you enter can determine your eligibility to get reimbursed.

Office tips for successful management of chronic condition management services:

Medical Home Coding Fact Sheet - The Americal Academy of Pediatrics offers a coding fact sheet that highlights most of the commonly reported codes for the medical home. This resource is updated annually to provide you with the most current coding information

Additional information and resources on coding can be found on the National Center for Medical Home Implementation web site.

Additional CPT Coding References
The new 2007 Supplement is available on the Illinois Academy of Family Physicians website entitled “Strategies for Billing, Coding and Getting Paid Appropriately – A Guide for Family Physicians.” A total of 645 changes have been made in CPT for the year 2007. While 258 codes have been added, more codes (308) have been deleted and 79 codes have received some type of revision. Overall, there are 50 fewer CPT codes in 2007 than there were in 2006.

Additional information and resources on coding can be found on the National Center for Medical Home Implementation web site.

Working with DSCC
DSCC recognizes that serving children with special health care needs is often more complex and time consuming. Chronic health care conditions generally require the expertise of a pediatric specialist. For these reasons, DSCC provides reimbursement to the medical home provider for telephone consultations with specialists and some care coordination activities. These are explained in a DSCC publication (Reimbursement Guidelines for Medical Home Services).
The primary care provider needs to be an approved DSCC medical home provider to receive reimbursement, and the patient must be both medically and financially eligible for DSCC support. The process to become a DSCC-approved medical home provider involves completing a basic application (which includes professional training and experience, taxpayer identification and legal status disclosure, and professional insurance verification) and successfully completing the DSCC Medical Home Primer exam and evaluation.

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A Model for Negotiating Contracts with Payers

A significant amount of income for your practice comes from successful contracting. The AAP, AAFP and AMA have developed online educational courses and resources to help pediatricians and family physicians successfully negotiate contracts.

Every practice may have 10-20 different health plans they contract with. Well-negotiated health plan contracts can increase revenue and reduce insurance company hassles by clarifying issues ahead of time. There is a distinct advantage when each practice has at least one partner with good skills in negotiating contracts. It’s important to review contracts annually, clarifying details and negotiating from the perspective of logic, fairness and need.

Contract Negotiations with Payers is an online PediaLink Course presenting tools and techniques to help physicians and staff successfully negotiate payer contracts with confidence. This course features a four-step process model to help course registrants plan and prepare, use leverage when negotiating, make informed decisions, and monitor compliance to contract terms and agreements.

1. You must have information about both partners in the negotiation.
2. You must understand and develop your leverage.
3. You must understand the timing of the negotiations both in the annual enrollment cycle for managed care plans and in the time you have dedicated to this particular negotiation.
4. You must understand the power of your organization.
5. You must be able to analyze all of the data concerning this process that you can discover and generate.

4 Phase Model of Successful Negotiation:

Initiate the Make Decisions phase:

Invest and commit to the Review Contract and Monitor Compliance phase:

Five elements to consider throughout the contract negotiations: