Pediatric Coding Alert

Sometimes parents request that their primary care pediatrician sees their new baby in the Neonatal Intensive Care Unit (NICU). However, payment for these services is very difficult. As Dawn Mercogliano, practice manager for Pediatric Professional Associates, a seven-pediatrician, one-nurse practitioner practice in Wayne, NJ, writes: We have been denied payment for procedure code 99295 (initial neonatal intensive care, per day). The insurance carrier claims that our physicians are not qualified to perform this special service because they are the primary care physician. Do you know of any other doctors who have encountered this problem?

Yes we do. And unfortunately, there isnt an easy answer. This is a situation in which an insurance company is very reluctant to reimburse, says Richard H. Tuck, MD, FAAP, of PrimeCare Pediatrics in Zanesville, OH, and a regional coding resource for the American Academy of Pediatrics. Medical management of the infant is probably already being done by the neonatologist. In particular, 99295, which is the initial code for the first day the baby is admitted and includes many procedures in the global fee, is not likely to be reimbursed twice (for both the neonatologist and the primary care pediatrician).

Two Basic Options

1. Dont bill. You might not be able to bill [or be reimbursed by] anybody, says Tuck. Instead, you can perform this service as a courtesy, realizing that eventually you will be following the childs care.

2. Bill a consultation. If no general pediatrician has been involved before, you can get called in as a consultant, says Tuck. But try to establish a diagnosis for the infant that is different from the one that the neonatologist has chosen, he says. If the neonatologist uses RDS (769), you could use feeding problem (779.3 ) or apnea (770.8). Both of these would be common close to discharge from the NICU if the child were premature, for example. The baby would probably be drinking milk and breathing room air. But the key is to use a different diagnosis from the neonatologist. This involves some coordination with the neonatologist, Tuck adds. But as a rule, pediatricians and neonatologists get along very well, so it shouldnt be too difficult to establish what diagnosis code the NICU is using.

Note: Another reason why the general pediatrician shouldnt use the neonatal intensive care codes is very simple: These codes cover a full days work, while the general pediatrician will only spend a short time from a few minutes to a few hours with such patients.

Diagnosis Codes and Consultations

You can only bill an initial inpatient consultation code (99251-99255) once during a patients stay in the hospital. But, during the initial consultation the pediatrician may need to order a lab test or radiology [...]