Pediatric Coding Alert

Question: Most payers haven't been paying prenatal visit code G9001. Blue Cross Blue Shield Carefirst (federal plan) rejects the code as invalid. Should I appeal the denials?

Maryland Subscriber

Answer: No, you shouldn't challenge the payer's ruling. Code G9001 (Procedures/professional services [temporary]; coordinated care fee, initial rate) is a temporary HCPCS level-II code that insurers created to gather statistics on the code's use prior to possible CPT inclusion. The payer probably doesn't accept the temporary code.
 
Even if BCBS considered G9001 a valid code, you're not guaranteed prenatal visit payment. The G900x codes don't contain relative values. Therefore, many insurers that recognize the codes may not cover them. 
 
Try this: Contact your insurance representative and find out what code BCBS accepts for a prenatal visit. Remind him that these claims don't list the pediatrician as the patient's "primary-care physician." Also, ask whether the payer covers a meet-and-greet visit. Even if the insurer doesn't normally cover the service, it may provide benefits for parents in high-risk situations.
 
If the insurer considers a prenatal visit a noncovered service, you could make parents pay for the visits. Have the future parents sign an advance beneficiary notice stating that if their insurer doesn't pay for the service, they will be responsible for payment.
 
Before billing the parents, discuss how this policy will affect your public relations. Many practices offer a meet-and-greet visit as a courtesy service that can generate future clients.
 
Good news: You have a specific diagnostic V code that you should link to the CPT prenatal visit code: ICD-9 2004 introduced V65.11 (Pediatric prebirth visit for expectant mother).

 - Answers to You Be the Coder and Reader Questions provided by Jane M. Dodds, MPH, FACMPE, former president of the Medical Group Management Association's Primary Care Assembly; Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics' national committee on coding and nomenclature; Linda Walsh, senior health policy analyst with the American Academy of Pediatrics Division of Health Care Finance and Practice; and Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at Catholic Healthcare Audit Network in Clayton, Mo.