Pediatric Coding Alert

Attendance at delivery (99436) is the code used by pediatricians who are requested to attend a birth by the delivering physician. Considering the fact that there is only one deliveryalbeit a multiple deliverycan you bill 99436 twice if there are twins? Many experts think so.

There is no question about 99431 (history and examination of the normal newborn) and 99440 (newborn resuscitation), both of which can clearly be used once for each child. But 99436, a new code as of 1998, is still unclear to many pediatrician practices.

We talked to four coding experts about this issue, and they all agreed, although with some reservations, that it is appropriate to bill 99436 twice for twins. As always with gray areas in coding, there is some disagreement.

Nevertheless, the consensus is clearly in favor of billing the code twice, for the following reasons:

1. Two patients, two bills. Its the same as if you see two children in the same family, says A.D. Jacobson, MD, FAAP, editor of the American Academy of Pediatrics book, Coding for Pediatrics, who says that you can bill 99436 twice. However, Jacobson, who practices in Phoenix, AZ, notes that you have to set up everything only once for twins.

Richard A. Molteni, MD, FAAP, a member of the CPT editorial panel, has a solution for this problem. He agrees that you can bill 99436 twice, since there are two examinations involved, as well as two minimal stabilization. Some of the time is reviewing the maternal chart and setting up for the delivery, adds Molteni, who is vice president and medical director of Childrens Hospital and Regional Medical Center in Seattle, WA. Nevertheless, there are two set-ups, and two patients. The review of the maternal chart isnt even included in the descriptor of 99436.

Modifiers such as -52 (reduced services) or -76 (repeat procedure by same physician) should not be necessary at all, since there are two different patients.

2. Two insurance forms = two patients = two codes. Victoria Jackson, administrator and CEO of Southern Orange County Pediatrics in Lake Forest, CA, agrees that you should bill the code twice. Jackson, who is in a very competitive managed-care environment and therefore accustomed to insurance companies refusing to pay for such things, says that in this case, the chances of the insurance company even realizing that the two babies are twins are slim. Since you have two separate HCFA 1500 forms, they might not even realize it, she says. However, she notes that if the health plan does know they are twins, you might have to fight. They might say, These were twins, you had to be there anyway, she says. You will have to explain that yes, you had to be there, but you also had to examine and stabilize two babies.

3. Two liabilities. Perhaps one of the most compelling rationales for billing twice comes from Allen D. Schwartz, MD, FAAP, of Pediatric HealthCare Associates in San Diego, CA. Youre doing two charts, you have two patients, and you have two liabilities, he says. That means you can bill 99436 two times.