Pediatric Coding Alert

Question:  Often, a parent will come in just for a baby’s weight check, but after the nurse weighs the baby, she’ll have to answer a long list of questions from the mother. How can we get paid for this time if the doctor doesn’t see the baby?

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Answer: You can capture nurse time by using a level-one office visit code (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). This code is specifically designed for services that may or may not require the skill and expertise of a pediatrician.

Code 99211 differs from the other office visit codes in two ways. First, code 99211 is included in the established patient office visit series (99211-99215) only. The new patient office visit codes (99201-99205) do not offer a similar nonphysician code. To report the nurse’s time, the pediatrician must have previously seen the patient.

Second, unlike the other office visit codes that require history, examination and medical decision-making, a level-one office visit does not require these three elements. So, to prove medical necessity for the nurse visit, E/M documentation should include:

• the complaint

• the assessment

• advice given

• the diagnosis.

For a nurse visit, typical complaints include infant spitting or concerns about weight gain. The nurse must take an assessment, such as checking the vitals, listening to the lungs, or a weight check. Record the progress of any weight gain or loss, such as “weight 10-6, up 6 ounces in one week.”

The nurse should also document any advice that she offers to the patient. The nurse may note that she recommended small frequent feeds, propping the baby up after feeds, or that she reassured the mother that the spitting was normal.

Link the E/M code to the diagnosis. Possible diagnoses include feeding problems in newborn (779.3), feeding difficulties and mismanagement (783.3). Remember that 99211 usually triggers a copayment, and families should be made aware of this.