Pediatric Coding Alert

Pediatricians are often assigned Medicaid patients born in the hospital who do not have their own physicians. Even if the pediatrician does not accept the child permanently, he or she must follow up on the care of patient while in the hospital, including discharge. If a child has high bilirubin levels, it is the pediatricians responsibility to make sure those levels are monitored until they go down.

For patients with hyperbilirubin, our office follows up on the test results on a daily basis after the patient is discharged, says Pat Collins, office manager for Southside Pediatrics, a two-pediatrician practice in Aiken, SC.

Sometimes there are three or four consecutive days of these tests, for which the child goes to the hospital. That means the pediatrician doesnt even see the child, but does have to write the order for the test, and call the lab to get the results. The practice must also call the parent to give them the test results.

Sometimes our nurses spend all day trying to track down these moms, says Collins, noting that these children do not end up as patients in the practice. Most end up going to a health department clinic for their care, she says. About 5 percent of Collins practice is Medicaid. Medicaid reimbursement is too terrible here, she explains apologetically. And there are quite a few of these children. Our hospital delivers about 1,200 Medicaid babies a year, says Collins.

The challenge is getting paid for all of this follow up. What Collins needs to know is if there is a code that she could be using when the patient is not in the office and all of the bilirubin tests are handled over the telephone. We talked to two billing experts for an answer.

1. Bill as a consultation, with caution. Depending on the scenario, you can bill a consultation code, Kelley Coccaro, insurance coordinator for Pediatric Associates, a seven-pediatrician practice in Danbury, CT, where 10 percent of the patients are on Medicaid.. If we have to consult with another physician in the hospital about bilirubin levels, and we have seen the patient also, we can charge a low-level consultation, she says; this would be CPT 99241 or 99424.

2. Bring the child into the office. It may be worth your while to draw the blood in your office instead of sending the baby to the hospital, even if its not your patient, says Donna Outen, insurance coordinator for Pediatric Associates of Kershaw County, a four-pediatrician practice in Camden, SC. They pay us for the drawing of the blood, although some companies only pay three dollars for that, says Outen. We just charge a venipuncture code (G0001) and an office-visit code, usually 99213, she says.

Tip: If the nurse draws the blood and the pediatrician doesnt see the patient, you have to use 99211.

Outen agrees that the Medicaid reimbursement is still low, even with this approach, especially considering the amount of work entailed in tracking down the patients. Outen says the pediatricians have discussed this problem, but have no choice about doing the repeat bilirubin tests. If we cant get paid, we still have to do them, she says. The doctors say its not worth the risk of not repeating them. And, at least if the test is done in the office, you can get some compensation for the work thats done.

3. Telephone codes. There are always the telephone codes99371, 99372, and 99373which are for talking to a parent or another health care provider for coordinating medical management. These codes would seem ideal for this situation. But you usually dont get paid for telephone codes, says Coccaro. Nevertheless, Collins is going to contact her Medicaid carrier to see if these would be appropriate for the bilirubin follow-up cases.

4. Appeal. Regardless of the way you choose to bill for these patients, the best strategy may be to contact your Medicaid carrier to explain the situation and agree on how this should be reimbursed. After all, the pediatrician must provide this care, he or she should be paid for it.

We have set up appeals to the medical director of the Medicaid carrier in these cases, says Coccaro. We appeal on the basis of the fact that we did not choose or accept the patient, Coccaro explains. We were just assigned the patient in the hospital. The appeal does take a little bit of work, the insurance expert warns.

We send a copy of the chart with our notes, she says. The pediatrician has to notate any services he provides in the chart. But the results are excellent: Nine out of ten times, they pay, Coccaro reports.