Pediatric Coding Alert

Question: How do we get paid for nurse time (CPT 99211 ), such as weighing in-office, premature babies (low weight), and answering mothers' questions? Michigan Subscriber Answer: You can capture nurse time by using a level-one office visit code (99211, Office or other outpatient visit for the evaluation and management of an established patient, that may or may not require the presence of a physician. Usually, the presenting problem[s] are minimal. Typically, 5 minutes are spent performing or supervising these services). This code is specifically designed for services that may or may not require the skill and expertise of a pediatrician. In addition, Medicare "incident-to" rules allow auxiliary physician employees, such as technicians or aides, to bill 99211, according to section 2051.1of the Medicare Carriers Manual. The assistant must be qualified to perform the service and be supervised by a physician who is present in the office.

Code 99211 differs from the other office visit codes in two ways. First, code 99211 is included in the established patient office visit series (99211-99215) only. The new patient office visit codes (99201-99205) do not offer a similar nonphysician code. To report the nurse's time, the pediatrician must have previously seen the patient. Second, unlike the other office visit codes that require history, examination and medical decision-making, a level-one office visit does not require the three elements. So, to prove medical necessity for the nurse visit, documentation should include: the complaint the assessment advice given the diagnosis. For a nurse visit, typical complaints include baby spitting up or Mom concerned about weight gain. The nurse must take an assessment, such as checking the vitals, listening to the lungs, or a weight check. Record the progress of any weight gain or loss, such as weight 10-6, up 6 ounces in one week. Document advice given. The employee may note that she recommended small frequent feeds, propping the baby up after feeds, or that she reassured the mother that the spitting was normal. Link the E/M code to the diagnosis. Possible diagnoses include feeding problems in newborn (779.3), feeding difficulties and mismanagement (783.3) or gastroesophageal reflux (530.81). Remember that 99211 usually triggers a copayment, and families should be made aware of this.