Pediatric Coding Alert

Plus: Pay attention to who actually performs the lab test.

Pediatricians perform phenylketonuria (PKU) screening tests frequently, but many practices are still unclear about how to report these screenings, particularly in light of conflicting information since the ICD-10 implementation. Consider the following three tips before you report another PKU service.

Tip 1: 99211 Is Not An Automatic Addition

A practice manager wrote to Pediatric Coding Alert to find out why her payer wouldn’t reimburse her for 99211 when she billed it along with 36415 (Collection of venous blood by venipuncture). In her office, the nurse draws the blood, takes a weight check and asks about the baby’s feeding habits. “Should we add modifier 25 to 99211?” she asked.

The reality is that you should not report 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…) if the baby is just coming in for a blood draw for the PKU screening, says Donelle Holle, RN, pediatric coding consultant and president of Peds Coding, Inc. “The first question that should be asked is what is the medical necessity for doing an assessment just to draw the blood for the PKU screening?” she says. “If the patient had a problem, then it would be okay.”

For instance, suppose the nurse performs the blood draw and weighs the baby. The weight is low and the mother explains that the baby is not feeding well. The mother demonstrates how the baby fusses while nursing, and the nurse works with the mother on a more effective breastfeeding method, showing the mother how to position the infant so she will consume more. In this case, you can report both 36415 and 99211-25. Link the PKU screening ICD-10 code (see Tip 3 below for more on this) to 36415 and link P92.8 (Other feeding problems of newborn) to 99211.

Tip 2: The Lab Should Bill 84030

Some pediatric practices report billing 84030 (Phenylalanine [PKU], blood) when they send a newborn screening test card to the state lab, but in actuality, you cannot report 84030 unless you personally perform the lab test for the PKU screening.

If you do perform these tests in an on-site laboratory, then you can report 84030. Otherwise, however, you should not bill the lab code. Instead, you’ll report the blood draw with 36415 and the lab will report 84030.

Tip 3: Insurers Vary on ICD-10 Code

Most pediatric practices can still cite the PKU testing code under ICD-9 (V77.3) off the tops of their heads, but that changed in October when ICD-10 took effect—and unfortunately, the code to which V77.3 crosswalks is not always accepted by insurers. That code—Z13.228 (Encounter for screening for other metabolic disorders)—may look right to coders, but some payers will balk at reimbursing you for it.

Even though the American Academy of Pediatrics states in its Bright Futures Guidelines that Z13.228 is the appropriate code for this service, a subscriber tells Pediatric Coding Alert that her insurer denies claims with Z13.228, stating that the diagnosis is “not valid for the setting.”

Unfortunately, a review of multiple insurance policies reveals that insurers vary widely on their requirements for reporting PKU tests. A Medicaid payer in Oregon wants practices to bill Z00.111 (Health examination for newborn 8 to 28 days old), while Cigna says to report Z00.121 (Encounter for routine child health examination with abnormal findings) or Z00.129 (Encounter for routine child health examination without abnormal findings).

Alabama Blue Cross/Blue Shield advises practices to stick with Z13.228, while United Healthcare’s policy says that it “does not have diagnosis code requirements for preventive benefit to apply,” leaving the choice to your practice.

The bottom line: Unfortunately, you’ll have to seek guidance from your payer until a national policy illuminates how to report a diagnosis for this service. In absence of insurer direction in writing, most practices opt to follow AAP guidance with Z13.228, but if your insurer requests a different code, you should heed their advice.