Pediatric Coding Alert

Now, there is no CPT code for providing lactation counseling. So, how can pediatricians help mothers succeed at breast-feeding? Its clear that patients want this service and that it is a good marketing idea to provide it. There are various ways that pediatricians can provide the service and get paid.

In a pediatric practice, lactation counseling could be done by a registered nurse (RN), an LPN, or an International Board Certified Lactation Consultant (IBCLC), says Marsha Walker, RN, IBCLC, past president of the International Lactation Consultants Association. Or the physician could be providing the counseling. Regardless of who is providing the service, the big question is: How do you get paid for it? And how do you get paid enough to cover an hours worth of counseling? Some options include:

1. Nurse-only involvement. This is when you would code 99211 (established patient visit, that may not require the presence of a physician). Whether the nurse spends 10 minutes or an hour with the mother and the baby, you could code only 99211. In addition, chances are that during the first few days, the nurse will receive phone calls from a distraught mother before breast-feeding really takes off. Many practices dont feel that they can spare this much nurse time. But for the simple, 10-minute checks which Walker says constitute some breast-feeding counseling cases 99211 is an option. But anything more than a simple check, when things are going well, is at least 30 minutes, she says. And a nurse cant do that, unless you have somebody designated for it. Just bear in mind that you may have to encourage your nurses, who are used to working quickly, to create a stressless and unhurried atmosphere for the mothers.

2. Pediatric nurse practitioners. Pediatric nurse practitioners can use the full scale of evaluation and management (E/M) codes, says Richard H. Tuck, MD, FAAP, founding chairman of the American Academy of Pediatrics (AAP) coding and reimbursement committee. They can code a 99215, if justified, notes Tuck, who practices with PrimeCare Pediatrics in Zanesville, Ohio.

3. Some pediatrician involvement. If a nurse does the counseling, you can only code 99211, says Walker. To code any higher than that, the pediatrician would have to step into the room. And that step into the room is key. The pediatrician can be briefed, and approve the setup, says Walker. That is enough to code a 99212 or higher. As long as there is some physician involvement in the face-to-face time with the mother and patient, you can bill a code other than 99211 (which pays minimally). Note, however, that this cant be just a matter of the pediatrician offering a word of encouragement there must be face-to-face time.

4. Comprehensive lactation services. This is an option for larger pediatric practices that want to be able to give mothers as much time as they need for lactation counseling. Many consultants schedule an hour, says Walker. If you bring a lactation consultant into your practice, how should you bill for her services? There are two main methods:

1. a pediatric practice (or group of practices) can hire a lactation consultant, compensate her, and do the billing for it;

2. get the lactation consultant a provider number to be used with a health plan and have the consultant do her own billing (this is for those health plans that will pay for lactation counseling usually one or two hour long visits).

5. Referrals to consultants. You dont necessarily have to have a lactation consultant in your practice, says Katherine Grimm, MD, FAAP, a pediatrician in private practice in New York. I think all pediatricians should have a list of breast-feeding consultants, she says. You can refer the moms to the consultants, and they can work out payment. This option works very well, especially considering that breast-feeding consulting is usually only a matter of one or two sessions. But you need to have that list dont expect a new mother to be able to find a breast-feeding consultant on her own. If a family is willing to pay the money privately, you should be able to provide them with the consultant, says Grimm.

6. The pediatrician as coach. Grimms preferred option is to provide the breast-feeding counseling herself. But she doesnt charge for it, explaining that Its done within the confines of an office visit. Grimm says she can tell who is going to need coaching and who isnt. I can predict as soon as I meet a mom who will have trouble breast-feeding and who wont, she says. If the physician is actually providing counseling, he or she can get paid for this based on time, notes Thomas Kent, CMM, CPC, president of Kent Medical Management, a coding and practice management consultant based in Dunkirk, Md. For 40 to 50 minutes of physician time, if more than 50 percent of the visit was spent on counseling, the office can bill the insurance plan for a 99215 office visit, Kent says.

Diagnosis Coding

The diagnosis code for lactation counseling is 779.3 (feeding problems in newborn). You can also use 783.2 (abnormal loss of weight), or 783.4 (lack of expected normal physiological development), if warranted by the infants condition. Although the main diagnosis code for lactation counseling would most likely be 779.3, the lactation counselor may actually discover some other problems as well. For example, there may be a fractured clavicle a common birth injury that sometimes goes unnoticed by the obstetrician and pediatrician, and its only when the mother tries to breast feed and the baby is too uncomfortable on one side that the problem is discovered. Or the diagnosis may be colic a problem that may not be discovered until the two- or three-week visit, says Tuck.

Warnings

There are two lactation counseling methods that Walker does not recommend: the public health nurse, and the nurse practitioner sent by health plans. The public health nurse isnt necessarily trained in lactation counseling, says Walker, and therefore can cause more damage than they think, because they cant tell if the baby is swallowing milk. As for HMO-sponsored counseling, that sounds like a great idea, but once again, Walker cautions that the nurse practitioners who are often sent on this mission may not be trained in lactation counseling either.

Note: Pediatricians who are interested in breast-feeding can join the Academy of Breast-feeding Medicine (for physicians only); the telephone number is (913) 541-9077, and the Web site is www.bfmed.org. If you are looking for an IBCLC, or want any information about breast feeding, contact ILCA at (919) 787-5181.