Pediatric Coding Alert

Here's one practice's success story

 If you want to offer expectant mothers an opportunity to meet your pediatricians but aren't sure how to bill this service without a specific CPT code, you'll be glad to hear that you can report a HCPCS Code for these prenatal visits. Read how one pediatric practice is using G9001 to get the service paid.

Explain What the Visit Entails

You should begin by emphasizing that these are prenatal visits, rather than courtesy visits, says Jane Dodds, FACMPE, administrator at Elmwood Pediatric Group in Rochester, N.Y. You should also take advantage of your nurse practitioners (NPs) to save your pediatricians' time.

To do this, Dodds' practice first has the pregnant woman, and usually her partner, meet with their pediatric nurse practitioner (PNP). "The PNP spends about a half-hour going over office policies, getting history for the records and completing paperwork," Dodds says. The PNP discusses normal newborn care, including when to call the practice, when to make the first visit, and what to expect during the first few post-hospital days. The expectant parents then meet with the pediatrician for about 10 minutes.

Negotiate for G9001, V65.11 Coverage

To encourage insurers to cover prenatal visits, explain that this visit saves the family paperwork at the newborn physical exam and establishes a relationship with the PNP and pediatrician. "In Rochester, pediatricians negotiated with the two major health management organizations (HMOs) for prenatal visit coverage," Dodds says. "If insurance doesn't pay, we charge the patient."

For years, Rochester pediatric coders used a "local" code to report the prenatal visit. But now they've agreed to use G9001 (Procedures/professional services [temporary]; coordinated care fee, initial rate), which identifies a professional service to establish coordination of care, Dodds says. G codes are temporary HCPCS level II codes that the insurers created to gather statistics on the code's use prior to possible CPT inclusion, according to HCPCS.

The temporary code coupled with ICD-9 2004's introduction of a specific diagnosis code for prenatal visits also signals a move toward better identification and reimbursement of expectant-mother prebirth visits. Now that V65.11 (Other persons seeking consultation; person consulting on behalf of another person; pediatric prebirth visit for expectant mother) is available, Dodds' practice will use the more specific diagnosis code. They previously used V65.1 (... person consulting on behalf of another person).

Free Visits Are Still an Option

Don't let public-relations concerns stop you from charging for these visits. Dodds' practice uses two tactics to deal with "shoppers." For potential clients to "get acquainted" with Elmwood Pediatric Group, the staff offers printed material. If pregnant mothers insist on a free visit, the receptionist schedules a PNP-only service.

To make coding and payment easier, get your receptionist to explain that these visits are billed as prenatal services, not freebies. Encourage her to explain to patients that they are coming in to establish a relationship with the pediatrician and PNP and not for a free advice meeting.

Limiting G9001's Frequency

To deter expectant parents' going to all potential pediatricians in an area, the Rochester HMOs limit pay for one G9001 prenatal visit to a pediatrician during a mother's first pregnancy. "If the patient goes to several doctors, they'll only pay one, which is a good reason to get our billing in quickly!" Dodds says. Elmwood Pediatric Group usually honors patients' requests to switch to another pediatrician within its 10-group practice.

Other practices also have policies to curtail pregnant- parent shopping. At Southern Orange County Pediatric Associates in California, they permit one free visit, says Victoria S. Jackson, group administrator. "If the mother wants to meet with another pediatrician within the group, we then charge the patient," she says.