Pediatric Coding Alert

Theres a wonderful new code for attendance at delivery: 99436 (see PCA January 1998). It is for the pediatrician to use when he or she is requested to attend a delivery, and does so, as well as stabilizing the newborn. It is not to be used in conjunction with 99440, the code for newborn resuscitation. In essence, it is a replacement for 99360, the code for standby services. Insurance companies do not generally pay for 99360 anyway (and it has a relative value of zero as far as the Health Care Financing Administration is concerned). So there are high hopes that 99436 will result in some reimbursement when pediatricians are asked to attend a delivery and the baby doesnt require special treatment.

But as everyone knows, having a new code doesnt necessarily mean getting a new fee. We called some insurance companies to find out how they are handling 99436. First of all, in the middle of February (press time) there was still great confusion among insurance companies about what these codes are. Most responded instantaneously with: We dont pay for standby. Yes, we know. But what about attendance at delivery and initial stabilization of the newborn? we asked. Well, we would cover it if it were a c-section, some said. Or, If its a high-risk pregnancy, you would be covered. However, theres nothing in CPT that says 99436 is for c-sections or high-risk pregnancies only. Its just for attendance at delivery, with initial stabilization. And as several insurance companies pointed out to us, all newborns need to be stabilized anyway. So this code is presenting a dilemma for the carriers, many of which arent sure what theyre going to do about it yet. At Prudential, 99436 wasnt even on the coding committees agenda for last month. And after it does get to the coding committee, it will probably have to be discussed by the reimbursement committee, says Anne Bisset, director of reimbursement policy for Prudential. The company should have a definite answer by summer. What are you supposed to put on your claims until then? Coding experts say correct coding indicates 99436, but we can't predict what the carrier will do.

At PacifiCare, however, the policy is to reimburse a pediatrician who is called to assist a child. If they are called to assist in stabilization, but did not need to do anything because the child stabilized anyway, we would cover it, says Alexandra Warnier, spokesperson.

At Independent Health, the answer is a definite yes for coverage. The New York State-based IPA was looking at all the new CPT Codes last fall, and has decided to reimburse for 99436.

Aetna/U.S. Healthcare is reimbursing for 99436, according to spokesperson Betsy Schmuck. Whether the delivery is c-section or a high-risk vaginal delivery, the company will pay for the attendance of the pediatrician, if he or she is requested to be there, says Schmuck.

Finally, BC/BS of CA says it is reimbursing for 99436.