Supporting Breastfeeding and Lactation: The …

1 Updated 9/2009 Supporting Breastfeeding and Lactation: The primary Care Pediatrician s Guide to Getting PaidBreastfeeding support can often be quite time-intensiveinitially but pays off in a healthier patient population. It is inyour insurers best interests that you provide theseservices, and be reimbursed pamphlet is a guide to help pediatric practitioners getpaid appropriately for their time as they incorporate morebreastfeeding support into their for problems with Breastfeeding and lactation is justlike billing for any other pediatric and other billable licensed practitioners(nurse practitioners* and physician assistants*) may: Use standard CPT codes, , 99212 99215 Use standard ICD-9-CM codes, , Code based on time, if greater than 50% of time isspent in counseling,education, or coordination of care Use modifier 25 appended to a separately reportedoffice or other outpatient service to bill for extendedtime spent on feeding problems at a well baby visit.

2 Bill for care provided for the mother, often as a newpatient, in addition to billing for the baby, if history,exam, diagnosis and treatment are done for practice can also, under specific circumstances,charge for services provided by nurses and such alliedhealth professionals as lactation consultants, healtheducators, and nutritionists, using a variety of used ICD-9-CM for billing the three-to-five day for extra time spent at well baby of time-based for for care provided for the for allied health professional services*Unless restricted by their state or payors scope of practice pamphlet does NOT discuss the detailed, important and specificguidelinesaffecting decisions about billing for nurse practitioners andphysician assistants, , whether credentialed and billed under theirown names vs. billing for their services incident to physician care andthus billed under the physician s name.

3 That topic is beyond the scopeof this pamphlet. However, all physicians employing such allied healthcare providers need to be aware of, and understand, the applicablebilling rules, and apply them carefully whether billing for feedingproblems, or for any othermedical services in the pediatric used ICD-9-CM codesBabyFeeding problemsFeeding problems/ slow feeding, vomiting in vomiting in problem, infant (> 28 days) , infant (>28 days) jaundice, and hydrationDehydration, to thrive, weight gain, FTT, infant (>28 days) well as all the diagnoses associatedwith size and crying, colic or intestinal issuesAbnormal in bowel arched specified follow-up (When the original reason for visit has resolved)MotherBreast& NippleissuesAbscess, breast/ Mastitis, milk duct/ Mastitis, engorgement, , or axillary breast specified nipple/breast specified nipple/breast , cracks or , nipple, (staph), nipple684 Candidiasis, nipple or sleep , failure to , , specified disorders of of specified follow-up (When the original reason for visit has resolved)Updated 9/2009 The three-to five-day visitThe AAP recommends1,2,3this visit to assess jaundice in ALL infants, regardless offeeding method.

4 To address other early feeding issuesFor Breastfeeding infants, the purpose of this visit is to assess weight, hydration and jaundice and to address the ability of the infant hydration growth and activity and maintain maternal assessment usually : Infant feeding, sleep and activity patterns,urine and stool output; maternal lactogenesis,comfort and : Weight, and exam for dehydration, sleepinessand level of indicated, observation of a feeding, includingweights before and after , interventions, and counseling if indicatedThe visit may be billed as either a first routine well visit OR a follow-up visit, for a problem noted earlierBilling as a well visitIf the infant s previous record does not document afeeding problem, and no other health problem has beenidentified, then this first office visitshould be coded andbilled as an established patient well-child visit.

5 CPT code 99391 ((and any other indicateddiagnosis codes, , for jaundice or feedingproblem)In any well visit, the clinician is expected to spend timeaddressing routine feeding issues. When unusual timebeyond the usual is required, there are two ways ofbilling for this extra extratime is required:If, a feeding problem exists which requiresmorethan anordinary amount of time to address, the physician may,depending on the circumstances, choose one or both ofthe following options, as clinically appropriate: Prefer to spend extratime at this visit to address theproblem immediately. This may then be billedseparately using the 99212-99215 codes appendedwith the modifier 25, following the guidelinesdescribed on the next page Schedule a follow-up visit, for example, within a fewdays, or at one to two weeks of age. That follow-upvisit would then be billable using the office follow-upcodes (99211-99215) related to that feeding and billing as a follow-up visitFor this to be billed as a follow-up visit,the reason forfollow-up must be clearly established on the precedinghealth or hospitalrecord.)

6 The earlier chart must document the unresolved problemthat requires a follow-up visit. An appropriatediagnosis code, , newborn feedingproblem ( ), or jaundice ( ) must beincluded with thehospital or birth center sdischargediagnoses, to establish the reason for the follow-up visit. Alternatively, telephone chart notes document that, sincedischarge, a new problem ofearlyproblems requiring follow-up include, butare not limited to: Jaundice Infrequent and/or dark stools Ability to transfer milk not established Infrequent Breastfeeding Weight loss exceeds 7% Breastfed infant being fed formulaOptions for coding and billingas a follow-up routinely with physician or billablelicensed health care provider ( , NP or PA):Use office follow-up codes99212 99215 andappropriate ICD-9-CM codes: Ifthe feeding problem persists, use an ICD-9-CMsuch as , , , etc.

7 If, however, the feeding problem has resolved, useinstead ICD-9-CM code , just as you wouldfor a follow-up resolved otitis visit with possible triage to physician orother billable licensed health care providerThis is aweight check and quick screen for feeding,sleep, and stool patterns. It is only billable to the nurseas a 99211 if it is NOT triaged to the doctor. Triagebased on adequacy of this visit demonstrates that good feeding hasbeen established,the physician does not need tosee the patient to bill for alimited nurse s visit withCPT code 99211 and ICD-9-CM code nurse s weight check visit reveals persistentproblems,you do NOT bill for the nurse visit butinstead triage back topediatrician, or other billablehealth care practitioner (NP or PA) immediately fora problem visit, billable as a follow-up visit(99212 99215)Updated 9/2009 Billing for extra time spent on feeding problems at any well baby visitIf, at a well visit, a significant, separately identifiable,diagnosable feedingproblemnecessitates extra timebeyond routine well visit feeding counseling, then the99212-99215 codes appended with the modifier 25 maybe reported in addition to the preventive medicineservice separate note is optimally written, on a separate pageor on the same page with a line separating the twonotes: the well visit note and the problem based , the problem-based note will require that allrequired key components of appropriatetime-basedbilling is documented for the code visits are thenreported, appendingthe modifier 25to theproblem-basedvisit example, using anestablished patient 8 to 28 days old, you would.

8 Some insurers do notrecognizemodifier for any clinician s visit based on timeBecause Breastfeeding visits are dominated by counselingand education, they can be CPT guidelines allow for a visit to be billed basedontime, rather than by meeting the E/M requirements forelements of history, physical, and decision-making, than 50% of the practitioner s face-to-face timewith the patient has been spent on counseling (patienteducation)or coordination of must documenton the total face-to-face time with the patient and/orthe patient s spentincounselingor coordination of care(and this must be > 50% of total) brief description of what was discussed (shouldbe one or more: diagnosis or impressions;prognosis; risks/benefits of management options;instructions for management and follow-up;compliance issues; risk factor reduction; patientand family education); a checklist on yourencounter form will make this easier for all time-based visits, not just those about breastfeedingissuesYou can bill for time for most routine E/M codes, ,99212 99215, when counseling,education, orcoordination of caredominate a visit otherwise not meetingcustomary guidelines for history, physical, and medicaldecision-making.

9 (but it should be noted that time-basedbilling cannot be used with the preventive medicine servicecodes, since their CPT code descriptors do not contain typical times )The CPT E/M guidelines for billing based on time:NewEstablishedOutpatientPatientTime PatientTimeConsultTime992022099212109924 1159920330992131599242309920445992142599 243409920560992154099244609924580[For example,if you spent 30 minutes face to face with anestablished baby and mother, of which greater than15 minuteswere spent counseling about feeding issues, you could bill withCPT code 99214, ignoring the usual history, exam, andmedicaldecision-making requirements for a 99214. Your chartdocumentation must include the three elements described above:total physician face-to-face time, total time spent counseling, anda description of that counseling.]ConsultationsThe physician or individually credentialed nursepractitioner or physician s assistant* may also bill theinitial feeding evaluation as a requested consultation ifthe following guidelines are met:A requested consultation (99241 99245)requires the 3 Rs, documentation on chart (whether verbal or written)from anotherphysician (even within the practice) or otherappropriate source (can be a lactation consultant oreven a La Leche League leader) is documentedandthe original request is to gather your advice oropinion.

10 This cannot be a transfer of service to requesting source (Note: must be awritten report.)Billing for codes 99241-99245 may bebasedeither onkey components or visitswill be billed as established patients(99212 99215).*An allied health car provider cannot bill a consult under the incident to billing options. Only a nurse practitioner orphysician s assistant who has been credentialed individually byan insurance company may bill for either of these types ofconsults under that provider s own name. Note: This is subjectto individual state and payor 9/2009 Billing for the infant s motherIf the physician or other billable licensed health careprovider is taking the mother s history, examining herbreasts and nipples, observing a feeding, and making adiagnosis and treatment plan for her, the clinician istreating a second patient. This may change the visit withthe baby into two separate and identifiable visits with twodifferent patients two patients, two visits, two records,two bills, and two co-pays.