Pediatric Coding Alert

Question: Our nurse practitioner often administers Synagis injections to premature babies. We're receiving denials stating the diagnosis code is not suitable for thechild's age. The babies are approximately six months old now but were preemies and need the injection. What diagnosis should we report other than 765.2x?

California Subscriber

Answer: Choose your initial diagnosis from 765.1x (Disorders relating to short gestation and low birthweight; other preterm infants) instead of 765.2x (... weeks of gestation). Some payers also expect V04.82 (Respiratory syncytial virus [RSV]) to help explain the situation, so check your payer's guidelines.

Code the encounter with 99211 (Office or other outpatient visit for the evaluation and management of an established patient ...) and append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Don't forget: If you are paying for the Synagis, you should also bill for the product. Report 90378 (Respiratory syncytial virus, monoclonal antibody, recombinant, for intramuscular use, 50 mg, each), a newly revised code in CPT 2010. Then add 96372 (Therapeutic, prophylactic, or diagnostic injection [specify substance or drug]; subcutaneous or intramuscular) to complete the claim.