Pediatric Coding Alert

Question: Pediatrician A performs a newborn exam in the hospital and bills 99431. Later on the same day, the baby becomes sick and Pediatrician A asks his partner, Pediatrician B, a neonatologist, to consult on the baby. Pediatrician B reports 99253.
 
I thought I couldn't report two E/M codes on the same day from the same practice on the same date of service. Is there a way I can bill for both pediatricians and receive payment?

Utah Subscriber

Answer: Because the neonatologist has recognized expertise in treating a baby who is sick, you may report a consult (99253, Initial inpatient consultation for a new or established patient ...) even though the two physicians are in the same pediatric group practice.
 
CPT allows a physician with recognized expertise in the same practice and the same specialty to act as a consultant. The encounter does, however, have to meet a consultation's requirements (written or oral request, written reason for the consult, written report, copy in the chart, and copy sent to the referring partner).
 
Although insurers often bundle same-day E/M services billed under the same group number, you shouldn't assume this scenario falls under that edit. Coding experts recommend rolling multiple same-day E/Ms involving the same diagnosis into one code. They base this advice on insurer policies, not on CPT guidelines that permit coding two same-day E/Ms, regardless of diagnoses.
 
Because your case deals with different ICD-9 codes, you should code each E/M service. When Pediatrician A examined the well newborn, she presumably used a normal baby diagnosis (such as V30.00, Single liveborn, born in hospital, delivered without mention of cesarean delivery). The consultation involves a physician with recognized expertise evaluating the baby for the problem she later developed.
 
Since you have different diagnoses, the insurer may cover both E/Ms. You should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99253 to indicate that the patient's condition required a significant, separately identifiable E/M service.
 
Make sure you link 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records ...) to the well diagnosis (for instance V30.00) and 99253 (Initial inpatient consultation for a new or established patient ...) to the sick diagnosis, such as tachypnea (770.6). If the payer denies one of the services, you could challenge the decision based on CPT rules.