Pediatric Coding Alert

Pediatricians often give advice over the telephone when a baby is born after they have done their rounds. Because you cannot bill until youve had the first face-to-face encounter, the only way to get reimbursed in this case is by going to the hospital to see the baby.

It happens all the time: A baby is born after the pediatrician has done rounds. The physician doesnt plan to return to the hospital to examine the baby until the next day at rounds. But a minor problem develops low blood sugar or low temperature. The hospital nurses call the pediatrician in the office for management advice, which he or she provides in between a full office schedule. Then, the next morning at rounds, the pediatrician does the first visit, billing 99431 (history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. [This code should also be used for birthing room deliveries.]).

The problem is how to bill for the first day, when the pediatrician has not seen the patient but is the one in charge of care. The process of managing treatment over the phone takes time and requires medical decision-making also, as pediatricians point out, it subjects them to possible liability.

You cant bill for that patient until youve had the first face-to-face encounter, says Charles A. Scott, MD, FAAP, a pediatric coding expert who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J. Its blatantly unfair, he adds. If something happens to the baby medically on that first day, the nurses will be calling you to get advice because its on your service, he says. You do a lot of medical work, but you cant charge anything thats the way the rules are.

Ricardo Garcia, CPC, CEO of DRG Associates Consulting Group, a coding and reimbursement consultant based in Denver, Colo., sympathizes with the problem. Its like a catch-22, says Garcia, who bills for 200 pediatricians. You have responsibility for the patient, but you cant bill anything.

Going to the hospital to see the baby that first day instead of managing the problem on the telephone is the only way pediatricians will be reimbursed. This is most convenient for pediatric practices that are close to the hospital where the baby was born. In this case, you would bill 99431 when you go to see the baby the first day, and 99433 (subsequent hospital care, for the evaluation and management of a normal newborn, per day) on the second day when you go for rounds.

You might think that you should be able to bill more than a 99431 if you make a special visit to the hospital to examine a baby that has a problem. But minor problems, such as low blood sugar or low temperature, usually would not warrant more than a level one or at most a level two hospital admission code (99221 or 99222), notes Richard H. Tuck, MD, FAAP, a coding expert who practices with PrimeCare Pediatrics in Zanesville, Ohio. In the case of low blood sugar or a low temperature, it would most likely be a 99221, he says. A 99221 has a relative value of 1.92, and a 99431 has a relative value of 2.06. So its clear that given these two choices, you would be better off billing 99431 anyway. If the visit does justify a 99222, that would be better than using 99431, because 99222 has a relative value of 3.16.