Pediatric Coding Alert

Sometimes parents request that their primary care pediatrician sees their new baby in the Neonatal Intensive Care Unit (NICU). However, payment for these services is very difficult. As Dawn Mercogliano, practice manager for Pediatric Professional Associates, a seven-pediatrician, one-nurse practitioner practice in Wayne, NJ, writes: We have been denied payment for procedure code 99295 (initial neonatal intensive care, per day). The insurance carrier claims that our physicians are not qualified to perform this special service because they are the primary care physician. Do you know of any other doctors who have encountered this problem?

Yes we do. And unfortunately, there isnt an easy answer. This is a situation in which an insurance company is very reluctant to reimburse, says Richard H. Tuck, MD, FAAP, of PrimeCare Pediatrics in Zanesville, OH, and a regional coding resource for the American Academy of Pediatrics. Medical management of the infant is probably already being done by the neonatologist. In particular, 99295, which is the initial code for the first day the baby is admitted and includes many procedures in the global fee, is not likely to be reimbursed twice (for both the neonatologist and the primary care pediatrician).

Two Basic Options

1. Dont bill. You might not be able to bill [or be reimbursed by] anybody, says Tuck. Instead, you can perform this service as a courtesy, realizing that eventually you will be following the childs care.

2. Bill a consultation. If no general pediatrician has been involved before, you can get called in as a consultant, says Tuck. But try to establish a diagnosis for the infant that is different from the one that the neonatologist has chosen, he says. If the neonatologist uses RDS (769), you could use feeding problem (779.3 ) or apnea (770.8). Both of these would be common close to discharge from the NICU if the child were premature, for example. The baby would probably be drinking milk and breathing room air. But the key is to use a different diagnosis from the neonatologist. This involves some coordination with the neonatologist, Tuck adds. But as a rule, pediatricians and neonatologists get along very well, so it shouldnt be too difficult to establish what diagnosis code the NICU is using.

Note: Another reason why the general pediatrician shouldnt use the neonatal intensive care codes is very simple: These codes cover a full days work, while the general pediatrician will only spend a short time from a few minutes to a few hours with such patients.

Diagnosis Codes and Consultations

You can only bill an initial inpatient consultation code (99251-99255) once during a patients stay in the hospital. But, during the initial consultation the pediatrician may need to order a lab test or radiology study, which means he or she would probably return the next day, read the result, write the opinion, and sign off, explains Thomas Kent, CMM, president of Kent Medical Management in Dunkirk, MD, and a former pediatric practice manager. This is a follow-up consultation (99261-99263). If, on the other hand, the pediatrician decides to assume a portion of the patients care and will be attending to the patient during their hospital stay, then you should use the subsequent hospital day codes (99231-99233). It is when both doctors are billing these subsequent care codes that they each must have a different diagnosis [in order to receive reimbursement], says Kent.

While it is excellent medical care for the general pediatrician to see the newborn in the NICU before assuming care, the insurance company would probably say this is unnecessary care, Kent relates. By using different diagnosis codes, you may be able to be reimbursed for the visit to the NICU.

Also, keep in mind that if you do decide to file for a consultation when you visit a baby in the NICU, you must have a request from the attending physician the neonatologist, in almost all cases for your opinion or advice. If this request is present in the hospital chart, then the pediatrician should examine the newborn and enter his recommendations into the hospital record, says Kent.

The bottom line here is that insurance plans will not approve of payment for a general pediatricians visit to the NICU unless there is a specific need for his or her opinion, Kent cautions, who recommends a courtesy visit on the day before discharge from the NICU, rather than using the consultation code. However, these situations are not always examined closely, says Kent. The pediatrician may feel it is worth the risk of an audit to bill a consult.

Neonatal Services Include

Neonatal critical care codes include the following services: Parenteral and enteral nutritional maintenance; metabolic and hematologic maintenance; pharmacologic control of the circulatory system; parent counseling, personal direct supervision of the health care team; and case management.

They also include the following procedures: Umbilical, central, or peripheral vessel catheterization; oral or nasogastric tube placement; endotracheal intubation; lumbar puncture; suprapubic bladder aspiration; bladder catheterization; initiation and management of mechanical ventilation or continuous positive airway pressure (CPAP); surfactant administration; intravascular fluid administration; transfusion of blood components; vascular punctures; invasive or non-invasive electronic monitoring of vital signs; bedside pulmonary function testing; and/or monitoring or interpretation of blood gases or oxygen saturation.