Pediatric Coding Alert

Pediatrics and obstetrics are by necessity closely intertwined at times, making coding and billing difficult. Take the case of a pregnant woman who is referred to you by her obstetrician (ob), who has diagnosed a fetal anomaly and wants to get your opinion on what should be done. Who is your patient, fetus or mother? How do you bill when there is no insurance (for the fetus)? And how do you satisfy the requirements of a consultation code if all you are doing is advising the mother on possible outcomes and her options?

Using Consult Codes

Lets take the last question first. The proper CPT Code for this visit is a consultation (99241-99245), but you must make sure that you are following the rules for consultations. There must be a request for a consult (from the ob). Andthis is the important part for pediatricians in this scenariothe pediatrician must document his or her opinion in the mothers medical record and communicate this opinion by written report to the ob. In other words, it is not enough just to tell the woman what the prognosis is. You must tell the ob as well.

Here is how Medicare defines the criteria for a consultation:

1. The consultation must be provided by a physician whose opinion or advice regarding evaluation
and/or management of a specific problem is
requested by another physician.

2. The need for the consultation must be documented.

3. After the consultation, the consultant must prepare a written report for the referring physician.

Tip: Because more than 50 percent of the time spent on this visit will be counseling, you can code based on time alone, notes Richard A. Molteni, MD, FAAP, a neonatologist who is a member of the CPT editorial panel.

If a pregnant woman comes to you on her own to talk about the fetus she is carrying, you cannot charge a consultation. The consultation must be initiated by another physician or other appropriate source, according to CPT, and a patient and/or family is not such a source.

Consider Both a Patient

Now, who is the patientthe mother or the fetus? Any debate is basically philosophical because you can only bill the mothers insurancethe fetus doesnt have any.

The mother and the fetus are the patient, asserts Richard H. Tuck MD, FAAP, of Primecare Pediatrics in Zanesville, Ohio. As long as the consult is requested by an ob, and the pediatrician satisfies the requirements of a consult, the encounter is billed as a consult for the mother to her insurance, says Tuck, who is the founding chair of the American Academy of Pediatrics committee on coding and reimbursement.

Molteni agrees. The dyad is the patient in this case, says Molteni, who is vice president and medical director of Childrens Hospital and Regional Medical Center in Seattle, Wash. They are considered a single patient, so the disease of the fetus is the disease of the mother.

But as mentioned above, regardless of who is the patient in philosophical terms, the mother is the patient for payment purposes.

Jean Pletl, ART, CCS-P, compliance and documentation specialist with Childrens Specialty Group in Norfolk, Va., bills consultations for these visits as well. We have a geneticist and renal doctor who sees these moms, says Pletl. The true patient is the fetus, she says. But the mother is the patient for purposes of the consultation.

Tip: Thomas A. Kent, CMM, president of Kent Medical Management in Dunkirk, Md., recommends making a temporary chart in the mothers name for this visit. Everything will need to go in the file, and the mother will be the patient, even for this short time. Later, if the child is born and becomes your patient, you can transfer this information to that file.

Pletl follows all the rules for consultations that she would for Medicare, although none of these visits are covered by Medicare. Thats because we say Medicare, Medicaid, and CHAMPUS in the same breath, she says. Yes, our doctors like to say, But this isnt Medicare. Like pediatricians everywhere, they dont understand what Medicare has to do with them. The answer isthose are the only publicized rules to go by. If were meeting the Medicare guidelines, then well probably have smooth sailing with everybody, says Pletl.

Pletl urges pediatricians to follow Medicares consultation guidelines, and to give written reports back to the ob. There are many things the pediatrician could have to say to the ob, which would also be said to the mom. There may be things the mom should do to alter the pregnancy, says Pletl. Maybe there are different treatments that can be done during pregnancy. All of this needs to go in the report.

Correct ICD-9 Coding is Essential

For the diagnosis code, use 655.xx (known or suspected fetal abnormality affecting management of mother). It is very important that you use the fifth digit for these codes, even though this section of ICD-9 only has four digits (the fifth can be found at the beginning of the 650-659 section). The fifth digit would probably always be 3 (antepartum condition or complication); the only other alternative would be 0 (unspecified as to episode of care or not applicable).

All of the 655.xx codes allow 0, 1 (delivered, or without mention of antepartum condition), and 3; 2 (delivered, with mention of postpartum complication) and 4 (postpartum condition or complication) are not allowed for this series. As examples of these codes, 655.0x is for fetal or suspected fetal anencephaly, hydrocephalus, or spina bifida (with myelomeningocele); 655.1x is for chromosomal abnormality in fetus, and 655.2x is for hereditary disease in the family possibly affecting the fetus. Other possible diagnosis codes are the 656.xx series (other fetal and placental problems affecting management of mother).

Its important not to fall into the trap of using diagnosis codes that could be applied to an adult, no matter how accurate you can be in the diagnosis, notes Pletl. For example, 740.x-759.x is for congenital anomalies. Specifically, 741.x (spina bifida) would not be used for a fetus. If you used this diagnosis code for the consultation with the mother, the insurance company might think that the mother was your patient and had that condition. You need to make sure the insurance company gets the message that its the fetus that has the anomaly, says Pletl. Otherwise they would think that we were treating the mom.

In fact, pediatricians would run afoul of their malpractice insurance carriers if they started treating adults. Thats why the question of who is the patient in this scenario is so tricky. Obviously, the mother is not really your patient the fetus is. But you must bill the mothers insurance. You wont be in conflict with scope-of-practice rules in these cases, says Pletl. Pediatricians are still doctors, she notes.