Pediatric Coding Alert

Question: If a PKU [test for phenylketonuria] is done in the office by nurses, and the visit includes cord care and answers to questions about feeding problems and other typical newborn questions, how should this be billed? We are currently using 99391 with a PKU diagnosis code (270.1).

Anonymous CA subscriber

Answer: If you are using 99391 (periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient; infant [age under 1 year]), then a pediatrician or a nurse practitioner (NP) must see the child for these visits as well. You cant use 99391 for a visit in which a nurse does a heel stick, cord care, and answers questions.

But if this is indeed a preventive-medicine visit with a pediatrician or a nurse practitioner, then you should also use the diagnosis code for a well visit (V20.2), in addition to 270.1. If a pediatrician is not seeing the child at the PKU visit, then you cant use 99391. If the child is seen by the physician for a quick check, cord treatment and answering questions the office visit codes (99212-99215); only use the well-care code (99391) if a full well-care service is provided by a physician or NP.

If a well visit is indeed conducted by the pediatrician, and the nurse does a heel-stick test for PKU at the end, you can bill for a heel stick using 36415* (routine venipuncture or finger/heel/ear stick for collection of specimen[s]). If the baby doesnt see the pediatrician at all, and just comes in for the test, you could bill a 99211the lowest level of established-patient office visit, which doesnt require the presence of a physician, as well as 36415* for the heel stick. Most of the time, however, when a new baby is brought into the office, the parents have so many questions that the pediatrician must be there. In this case the pediatrician usually prefers to talk to the parents and see the babyeven if it is just to take a peek and make sure all is well. A common mistake is for the office to bill 84030 (phenylalanine [PKU], blood).

This is the PKU code that the lab uses for actually performing the lab analysis; the office is only collecting the specimen. However, sometimes this is not a mistake: The pediatrician must use this code. This happens in the case of some state labs that charge the physicians office for the PKU test itself, which the physician must then bill to the insurance company. In this case, the state instructs the office to bill 84030-90. The -90 modifier (reference [outside] laboratory) indicates the office is billing for the lab performed by a reference laboratory. It is to be used when laboratory procedures are performed by someone other than the treating physician.

Note that the code for the heel stick (36415*) is a starred procedure. This means that an office visit may be billed in addition to the procedure, even though it is considered a surgical procedure. The usual package concept, or global fee, doesnt apply because the pre- and postoperative services are so varied. If, however, nothing is done but the heel stick, then you probably would not bill an office visit. As CPT states: When the starred procedure is carried out at the time of a follow-up (established patient) visit and this procedure constitutes the major service at that visit, the service visit is usually not added.