Pediatric Coding Alert

When a new mother is having problems breast-feeding, its definitely a pediatric concern. The American Academy of Pediatrics recommends that babies get breast milk exclusively for the first six months of life, and then add solids, with breast milk being continued until the child is at least one. If a new mother is having difficulty in the early days, she will be discouraged, the child may not gain weight, and the temptation to go to formula will be great. Therefore, many pediatric practices are trying to encourage breast-feeding. This often means having a nurse help a new mother with techniques. But how can you get reimbursed for such a service?

At Woodburn Pediatric Clinic, a three-provider (one pediatrician, one physicians assistant, and one pediatric nurse practitioner) practice in Woodburn, OR, the nurse does the lactation counseling. The service takes around 30 to 60 minutes, says Andrea Redlinger, office manager. We have been trying to figure out how to bill this service and get reimbursed for the time spent.

These sessions with new moms do indeed take timeits not something you can rush. Some practices even send their nurses to breast feeding seminars, so they can provide the best information possible. But if a nurse is spending half an hour or more doing such work, its understandable that reimbursement becomes an issue.

Most practices contacted by PCA are providing such services for free, but wish they could be reimbursed. We did find two practices which have solutions to the dilemma, however.

1. Bill an office visit under the physicians name. This is what Dee-Jay Beard, office manager for the Pediatric Center in Stone Mountain, GA has been doingwith great success. We have a clinical nurse specialist who does lactation consulting, says Beard. She happens to be a certified lactation consultant, but its not required. She knows its not required because the services arent even billed under the nurses name. Weve always billed under the doctors name.

The first lactation counseling visit is done with the baby is three to five days old, says Beard. A 99214 is charged, as well as a prolonged services (99354-99357) code, if the visit lasts for an hour. Ninety percent of the practice is managed care, and there have been no problems paying for the 99214, she says. Sometimes prolonged services are a problem. But then all we have to do is send a copy of the chart notes, and we get paid for the prolonged services too, says Beard.

After the first visit, the new mom goes back to the practice within the week for a second session. This second session is usually a 99213 or 99214. By then, there usually dont have to be any more sessions. Breast-feeding is off to an excellent start.

2. Pay attention to ICD-9 code. The diagnosis code used by Beard for these sessions is 783.3 (feeding difficulties and mismanagement). By the way, Beards practice also rents breast pumps to its moms. This is another way to make money, says the office manager, who adds that she had no idea other pediatric practices did lactation counseling without charging for it.

3. Refer to the hospital. Another option is to refer new moms to the lactation specialist at the hospital, says Cherice Swick, billing office coordinator for Pediatric Care of York, an eight provider (seven pediatricians, one nurse practitioner) practice in York, PA. The practice has privileges at the hospital, and most of the mothers have delivered there. This way, the hospital deals with the billing. This also avoids the conflicts that sometimes exist in breast-feeding philosophy and technique, with hospital nurses advising one thing and nurses at pediatric practices advising another.