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.
-top of page-
Coding & Billing for the Care
and Services Provided
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
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
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:
The physician doesn’t choose the most precise
code to reflect time, history taking or decision making activities
that occur during the visit.
The documentation of the visit doesn’t support
the use of higher intensity evaluation and management codes.
Codes that may be used for Medical Home care coordination
activities are under-utilized.
-top of page-
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
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.
-top of page-
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.
-top of page-
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:
Examining CPT code distribution for all children
and comparing it to the distribution of CPT codes for children with
special health care needs.
Analyzing any difference between the two populations
of children. He says “The distribution should not be similar;
if they are, the practice is not fully and appropriately utilizing
the richness of CPT coding to capture the true nature of services
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:
Extent of history of presenting problem(s)
Comprehensiveness of the examination
Decision-making for the presenting problem(s)
Coordination of care
Nature of presenting problem(s)
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:
Investigating codes covered by local insurance carriers
to enhance proper reimbursement for billing.
Billing for care that is typically not reimbursed
(i.e., telephone conversation prior to an office visit if the visit
is impacted by the telephone conversation).
Determining if a child may be eligible for KidCare
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.
-top of page-
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
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.
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.
Code 99358 is used for the first 30 minutes to an
hour of service, and
code 99359 is used for each additional 30 minutes
or for the final 15 to 30 minutes on a given day.
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.
-top of page-
Physicians provide a number of services with no direct patient contact
that are strictly time dependent. These include the following:
Creating a System for Managing Care Plan Oversight (CPO)
Establishing a monthly routine is the best way to ensure you are paid
for your CPO services. Here's one approach: First, create a log of all
patients for whom CPO is provided each month. This list will remind
you which charts to pull at the end of the month when it's time to submit
claims. Second, keep a CPO log in each patient chart and document the
date, total time and a brief description of the services each time you
provide them. Be sure to sign the CPO documentation.
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
-top of page-
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
Identify eligible patients, if billing to state programs
Keep billing form in front of chart
Train all staff to document care coordination activities
Meet with your billing department to discuss strategies
on how to bill for these codes. (For example, Title V may not be the
payer of last resort in this situation and may be the first designated
payer for these codes. Some systems are set up to bill private insurance
and then Medicaid and then Title V so you may need to work on a new
system to bill this properly.)
Design a system for your practice on how to tally
and submit billing information.
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
Center for Medical Home Implementation
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
Center for Medical Home Implementation
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.
-top of page-
A Model for Negotiating Contracts
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
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.
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.
There are five elements that are crucial to successful negotiations:
You must have information about both partners in the
You must understand and develop your leverage.
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.
You must understand the power of your organization.
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:
Prepare and plan for the negotiation. Set goals.
Be the best negotiator you can be.
Make the decisions to finalize the negotiation.
Review the final contract in order to understand all of its terms.Monitor
compliance with those terms.
Begin with the Prepare and Plan phase:
Look first at the top 10 CPT codes for which you bill. Define
priority contract issues, including provisions/what services are important
Identify your goals, desired outcomes, needs, and wants –
and reason (s) why you want the outcome.
Collect and analyze data about your practice performance. Document
the quality of care you offer. Assess the market, different payment
models, physician numbers, geography, patient volume, largest area
employers, and other areas that relate to your practice.
Identify your strengths (your niche).
Determine who it is that you will be talking to in each step of
the negotiation process. Identify the decision-maker representing
the payer on your contract.
Research payer interests, needs, and wants, including ascertaining
what you perceive to be their interests and desired outcomes.
Know federal and state antitrust law, as it applies.
Plan your strategy and create your agenda… then prepare
to work it. Plan your strategy and approach to implement your agenda.
- Rehearse important parts of your agenda and negotiating position.
- Set your target based on your goals and identify your options, alternatives,
and compromise level.
-top of page-
Invest time and energy in the Negotiation phase:
Orient yourself toward a successful negotiation. Implement your
planned strategy and approach.
Establish rapport in phone and face-to-face meetings.
Take an active listening stance and skills into every meeting.
Focus on understanding… and on being understood.
Reassess your pre-determined negotiation style based on what you
observe and perceive early in the meeting (s). Adapt your style, if
Assert your needs clearly. Align your responses and overall path
forward with your expectations, goals, outcomes, needs, and wants.
Acknowledge the payer’s representative as a person and recognize
the payer’s point of view.
Ask problem-solving, open-ended questions to gain deeper understanding
and encourage dialog. Why? Why not? What if?
Review and refine options. Brainstorm possibilities and ideas for
Focus on needs, interests, and concerns. Deal effectively with
objections and dishonest tactics. Manage impasses with patience and
respect. Clarify issues and feelings. Counter offers, using persuasive
and bargaining skills.
Initiate the Make Decisions phase:
Identify signals that could indicate it is time to begin closing
Restate and evaluate options. Pick a solution (or solutions) from
the options, adjust, and work to agree on preliminary outcomes. Build
Decide when to close for agreement, defer/delay, or walk away.
If you decided to defer or delay negotiations at this or some other
point, evaluate when or if it is reasonable to return to the bargaining
table at a later time with new options or explore other payer options.
Close for agreement.
Recap/summarize to ensure that all parties are clear on agreed
End the meeting with a mutual commitment to implement determined
plans. Build an opportunity to check back with each other to evaluate
progress on implementation.
Invest and commit to the Review Contract and Monitor Compliance
Review/evaluate the contract.
Conduct a legal review to ensure that the contract is legally binding.
Have both parties sign the contract.
Evaluate the negotiation process and results.
Implement the contract. Ensure that all pediatricians and staff
in your practice are fully informed as to all provisions of the new
Monitor compliance by the payer and enforce contract provisions.
Establish a formal review process to evaluate the overall impact
of the contract on your business, patients, practice, and staff.
Renew, replace, or terminate the contract. Make your decision
based on the payer’s performance and the value the relationship
brings to your practice.
-top of page-
Five elements to consider throughout the contract negotiations:
Analysis is the process of considering something in detail to discover
the relationship and meaning of parts to each other and the whole.
Give careful thought to your negotiating strategy, proceeding
thoughtfully and methodically based on clear goals, positions, and
interests. Know your bottom line. Just how far are you willing to
Determine relevance and usefulness of every point of the agreement
and how these points relate to your goals. Break down and study
all aspects of the negotiating process before, during, and after
each step. Start by determining priority contract issues and examining
data related to your practice and the payer in your planning.
Keep a clear head to make logical and best decisions, taking
time outs to rethink your approach if necessary. Try to figure out
the best resolution you can expect.
What is a fair and reasonable deal – and what is a minimally
Time is the measurable period during which an action, process,
or condition exists, continues, happens, begins, or ends.
In a negotiation, use time as an asset, resource, and tool
to your advantage throughout the entire process.
Define the period over which negotiation phases will take place
and address factors that relate to time. How long will you allow
for initial and follow-up negotiating sessions? What is the most
advantageous moment in the relationship to schedule negotiations?
You don’t want to be rushed or distracted by other activities,
so schedule enough time. What is the best time of day to schedule
the negotiation? What is your deadline for back and forth proposals?
What is your timeframe for having a signed agreement?
Don’t be pressured into making decisions in haste. Most
negotiations will conclude in the final 20% of time allowed.
Use time wisely – make it your ally.
Power is the possession of mental or physical control, authority,
or influence over people or situations. Using power to influence people
or situations is an important aspect of negotiations.
How can you develop power or what can make you feel powerful
in a negotiation? It can come in many forms, such as position,
knowledge, character/ethics, gender, charisma, and even the appearance
Most importantly, you can gain power in a negotiation through
thorough preparation, asserting your needs, educating the payer,
and even by dealing effectively with objections or dishonest tactics.
Use power constructively in a negotiation.
Information is knowledge, intelligence, or data obtained from
investigation, study, or instruction. It can be acquired by telephone,
e-mail, hard copy, or in person. Information (facts, statistics, background,
past experience, etc.) is critical to have and use effectively in
negotiating with a payer.
The more information you have on your position and the more
you know about the other side, the better you can establish your
Research, learn, listen, and ask questions to gain information.
What information do you have about your practice and its’
relationship to the payer and what do you need? What does the
payer need from you? What are the payer’s and your competitive
advantages and disadvantages?
Information = Power
Leverage is your ability to effectively obtain agreement and achieve
a goal on your own terms – your strategic advantage. It is dynamic,
based on perception and fact. Leverage is different from power in
that leverage is about situational advantage, not objective power.
You can exert considerable leverage under the right circumstances
with very little conventional power.
Recognize options (alternatives) on both sides of the table.
Appreciate how willing you are to consider those options and know
what the bottom line is for you and the payer.
Knowledge and insights into the relative strengths of you
and the payer are important to create leverage. Which side has
the most to lose? Can you gain control over something the payer
needs? Can you commit the payer to terms that favor your practice?
For who is time a greater factor?
Data is especially important in creating leverage. Before
entering negotiations, gather as much information about your practice
as possible, such as quality rankings, patient volume, financial
data, patients to be served, geographical needs and coverage,
and physician provider panels. Also gather external information
such as services provided by other pediatricians in the area and
current quality and quantity of pediatric services.
To get a sense of how leverage will play out in a negotiation,
“Who has the most to lose if there is no contract?”
-top of page-