Pediatric Coding Alert

Question: Our pediatrician is part of a team of professionals treating an eight-month-old patient with a swallowing disorder that prevents the child from taking in enough breast milk. We submitted our physician's charges for his E/M services forthis patient to Aetna but the claims manager keeps asking for additional documentation. Should we keep sending it, or should we append a modifier of some sort to get this claim moving and denote that we are part of a team treating this patient?

Answer: Insurers often maintain comprehensive policies that describe the criteria you must meet when working as part of an interdisciplinary group, so your payer is most likely trying to ensure that you've met all of the requirements for treating the patient's swallowing disorder.

According to Aetna's policy bulletin on pediatric intensive feeding programs (#0809), updated on Nov. 19, an interdisciplinary team can treat complex feeding/swallowing disorders in children and infants if all of the following conditions are met:

• Behavior problems that interfere with feeding
• Diagnosis-specific treatment plan with child-specific interventions and documentation of estimated length of treatment
• Medical causes of failure to thrive have been treated without resolving the feeding issue
• Neurological or oral-motor problems exist
• Normal feeding milestones have not been met
• The physician coordinates and oversees the treatment program
• Suboptimal score on nutritional assessment has been documented
• Unresponsive to initial treatment efforts by a single discipline over a two-month period.

Based on the fact that your payer is asking for additional information, it's likely that no modifier will change your payment status; instead, check to ensure whether you've met all of the criteria listed above to meet the medical necessity guidelines. If not, submit the missing documentation and if that doesn't work, contact your payer representative to find out how to proceed with collecting for your service.

Keep in mind that if you don't meet every one of the eight criteria listed above, Aetna will most likely consider your claim non-payable.

To read Aetna's policy, visit www.aetna.com/cpb/medical/data/800_899/0809.html.