arosborne
New
We have a solo pediatric infectious disease specialist who sees many neonatal patients in NCCU. All other insurance companies (mostly Medicaid products) pay when he bills 99291/99291 for these patients who are very young and critically ill. We have 1 insurance company that refuses to read and correctly interpret the CPT book. They refer to 1 paragraph in our states Medicaid provider handbook which only pertains to 1 scenario where the codes 99291 and 99292 are used. They hold strong to the age relation of codes 99468-99476 and insist that is what has to be billed. Of course, by the time that our provider is called in, the attending physician in NCCU has already billed a code from range 99468-99476 and per coding guidelines and this quote from AAPC Coder "Remember, that global neonatal and pediatric critical care codes, 99468 to 99476, Inpatient Neonatal and pediatric critical care services are for full day inpatient services. No two providers can claim same day, per day, critical care, for the same time period or day", our doctor can not bill from this range without a certain denial for the code having already been billed by other provider. There are no appropriate modifiers our specialist can use either. Under the Inpatient Neonatal and Pediatric Critical Care section of Evaluation and Management/Inpatient Neonatal Pediatrics, Neonatal Critical Care Services Section of the book, it clearly states that “If the same individual provides critical care services for a neonatal or pediatric patient less than 6 years of age in both the outpatient and INPATIENT settings on the same day, report only the appropriate Neonatal or Pediatric Critical Care codes 99468-99476 for all critical care services provided on that day. Critical care services provided by a second individual of a different specialty not reporting a per-day neonatal or pediatric critical care code can be reported with 99291,99292.” The 2nd individual of a different specialty comment is added to this rule because only 1 provider per day per patient’s stay in that scenario (ICU/NCCU etc.) can bill a code from 99468-99476. Obviously the providers who don’t bill the 99468-99476 for each day have to have a code to get paid from and that is why this rule on 99291, 99292 is there. Correct? Has anyone else who bills for a specialist called into NCCU had this problem with an insurance company? If you have, you probably know exactly which one I am referring to. Thank you in advance for any experience feedback. All of the "expert" articles out there (and I have looked at a ton) are very careful to just refer you to the coding guidelines in the CPT book when it comes to neonates and peds in critical care scenarios. It seems that it's not black and white enough for the writers to put their comments around the situation. Thank you again for your input! 
