Billing 101

Billing 101 – Green Road Pediatrics Services and Billing Practices

Our goal is to inform you of the comprehensive care that your child receives at Green Road Pediatrics, to clarify our billing practices and to show our most common fees. This will enable you to anticipate and to understand the proven “best practices” of well childcare and ill childcare and to allow you to more easily navigate the complexities of insurance coverage. Insurance companies are passing more and more healthcare expenses to parents. It is our intent to provide the best care for your children according to proven best practices and not to burden you with unanticipated expenses.

 

Well Childcare – We follow recommendations for preventative healthcare, including vaccinations, as defined by the American Academy of Pediatrics and Bright Futures from the U.S. Dept. of Health and Human Services. In addition to obtaining an interim developmental, nutritional, behavioral, academic, family and social history, performing a physical exam and discussing anticipatory guidance, the following measurements, screenings, procedures and assessments are recommended.

• Measurements – Length/height, weight, head circumference, Body Mass Index and blood pressure are recorded and compared to previous records as appropriate from infancy through young adulthood.
• Vision and Hearing Screening – Vision is assessed by physical exam for all young infants. Automated vision screening technology allows us to comply with new recommendations for instrument vision screening from 1-5 years of age. Our goal is to detect amblyopia or the risk of developing amblyopia, which currently affects 1-4% of young children. Vision screening is done every other year from 6-12 years of age and as indicated. Audiometry testing is done at 4, 5, and 6 years of age and every other year until age 12.
• Developmental /Behavioral Assessments – developmental delays and autism are assessed by parent questionnaire at 12, 18, 24 and 36 months of age. ADD, depression and alcohol/drug abuse assessments are done as indicated.
• Screening Tests – Hemoglobin and blood lead are checked between ages 1 and 2 years and each as indicated at other ages.  Testing for tuberculosis, high cholesterol, and sexually transmitted infections is completed when indicated.
• Diagnostic Tests – Rapid tests for detection of strep, influenza, and RSV as well as urinalyses are completed as clinically indicated. 
• Fluoride Treatment – Fluoride varnish application to the teeth for the prevention of dental caries (cavities) is recommended every 3 to 6 months at regular well child care visits starting with the eruption of the first tooth until age 5 years.  We will provide it here in our office until you child starts to receive routine care from a dentist.

 

The Affordable Care Act mandates that insurance plans cover these standard of care services. However, until fully implemented and enforced, not all insurance plans are covering these fees and are either adjusting them off, passing them on to the responsible party or applying them to an agreed upon deductible. It is not possible for us to know the various terms of each insurance plan. Parents need to know the limits of their insurance plan and budget accordingly.


Coding of Medical Services and Fees – Our coding practices are in accordance with national coding standards, defined by the Department of Health and Human Services and widely accepted by government and private health insurance companies.

• Well Childcare – Coding and fees for well childcare visits are based on age, whether the patient is new or an established patient to our practice and are consistent with community standards.
• Ill Childcare – Coding and fees for ill childcare visits or “evaluation and management” (E/M) visits are defined according to precise standards determined by depth of history taking, complexity of past medical, family and social history, extent of physical exam, complexity of diagnosis options, amount and complexity of data to review, risk of complications and complexity of decision making. Today’s electronic medical record software makes this calculation according to data entered. The appropriate level of complexity for each office visit is confirmed by the examining physician before charges are submitted to the insurance carrier.
• Combined Well Childcare and Ill Childcare – Occasionally, during a well childcare visit, a distinct and separate concern is raised by parents/patients or is detected by the physician that requires significant and separate E/M services. Common examples are when a child becomes ill a day or two prior to a well childcare visit or when presentation of academic, behavioral or chronic concerns are delayed until the next well childcare visit. In these circumstances, it is customary to code for the well childcare visit plus the E/M service, in which case a copay for the E/M service is often due. This is accepted by all insurance plans that we accept. Though this is often convenient for parents, we prefer separate visits so that adequate time is spent addressing both well child issues and other separate concerns.