Pediatric Coding Alert

Pediatricians who are requested to be at a delivery now have a code they can use for that service. As of January 1, 1998 you can use 99436 for attendance at delivery. Dont even think of using the code for standby services (CPT 99360 ) any more.

The descriptor for 99436 is: Attendance at delivery (when requested by the delivering physician) and initial stabilization of a newborn.

The AAP requested the code for attendance at delivery because the only one that existed before was simply not accurate. Standby services indicates that the pediatrician isnt doing anything, the AAPs Office of Physician Payment Systems tells us. But they are doing something, and they need a code for it.

What the physicians are doing is initial stabilization. Any doctor will be able to use the code -- pediatricians, neonatologists, obstetricians, family physicians -- no code is doctor-specific, only procedure-specific. But it may be a relief to pediatricians to be able to code for what they are doing. For years pediatricians have been going to deliveries and havent been able to record, document and get reimbursed for what they are doing, the AAP notes.

While the new code is good news for pediatricians, will it really mean that health plans will start reimbursing them for attending normal deliveries? Possibly, because the very word standby is not in the descriptor. The term standby in the old description is the one word that lead managed care organizations to believe that pediatricians werent doing any work while attending the delivery. They were just standing by, notes Charles Vanchiere, MD, FAAP, CEO of an eight-physician group practice in Lake Charles, LA. But its ultimately a payor issue, admits Vanchiere, who also chairs the AAPs RBRVS Project Advisory Committee.

We have to use the new code and hope the payors reimburse for it, says Steven E. Krug, MD, FAAP, specialty advisor for pediatrics to the AMA RUC and a member of the AAPs RBRVS Project Advisory Committee. But the presence of a code does not assure reimbursement, adds Krug, who is associate professor of pediatrics at Northwestern and head of pediatric emergency at Childrens Memorial Hospital, both in Chicago. He notes that the pediatrician does do a considerable amount of work when he or she is summoned to a normal birth. And he adds that all of this work must be documented and should be reimbursed. Pre-service work includes showing up, reviewing the maternal records, talking briefly with the family, scrubbing, and preparing the warmer and resuscitation equipment, he explains. Delivery includes a brief assessment of the infant, one- and five-minute Apgar scores, and standard healthy newborn resuscitation, such as drying, stimulating, and suctioning.

About 20 percent of deliveries are identified as high-risk, and require the presence of a pediatrician, Krug tells us. These include c-sections, situations in which there is fetal distress, and excessive prematurity. The pediatrician has to be there in case he is needed for a sick baby who may need resuscitating with continuous positive airway pressure or chest compressions (neonatal resuscitation: 99440). And as Krug puts it, the doctor needs to be there if he is called, period. Even if the child turns out to be healthy, he still does work. He clearly isnt just standing by, says Krug.

Do you need to document what the reason was for your being called and why the delivery was viewed as high risk? Its useful to put in, says Krug. But the point is that if you are called, you have to go, and you are doing some work. So you have to code for it -- making sure you document the work you do. The documentation goes in the babys chart. And remember that this is not the same as a newborn history and examination (99431 to 99435).

Documentation Suggestions for the New Attendance at Delivery Code New codes are fine, but the real question is whether payors will recognize them. This is an essential question, too. Because once you start coding something, such as attendance at delivery, it goes on your books. In light of how payors regarded standby services -- totally unreimbursable -- they may think that attendance at delivery is just a replacement for it, and refuse to pay for the new code as well. We know its not a replacement -- youre doing something (stabilizing a newborn) -- but it may take time for the message to filter through to managed care. As with many new procedure codes, you should anticipate either denials or requests for additional information from insurance carriers. But here are some tips: It will help if you include adequate documentation in the babys chart. In addition to your newborn care notes, document the total time you spent in attendance at delivery, and a detailed account of the care you provided to initially stabilize the newborn. Touch base with the delivering physician to make sure he has documented that he requested your presence at the delivery. This documentation must be within the hospital medical record. If the new codes are denied you could try resubmitting them as inpatient consultations (99251-99255).