EM Coding Alert

Question: Our pediatrician admits a newborn baby with severe respiratory distress and we reported 99468. The baby is discharged six days later, but the physician has to admit the baby two weeks after (at 22 days old), critically ill with neonatal sepsis. This by definition does not fit within the criteria of “per hospital stay,” as this is a different hospital stay. Therefore, could I report 99468 again?

Ohio Subscriber

Answer: You can absolutely report 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for the subsequent admission, since it involves a separate hospital stay. Link the first admission to the RDS diagnosis (769) and the subsequent admission to neonatal sepsis (771.81).

Introductory notes in CPT® before the Inpatient Neonatal and Pediatric Critical Care range (99468-99476) state that 99468 and 99469 “may be reported only by a single individual and only once per day, per patient, per hospital stay in a given facility,” CPT® states. “If readmitted to the neonatal critical care unit during the same day, report the subsequent day(s) code 99469 for the first day of readmission to critical care, and 99469 for each day of critical care following readmission.” However, even though this language offers a clarification to existing policy, it brings up additional questions.

Alternate example: If, however, the patient was still in critical care during her initial stay, had transitioned to a lower level of care, and was about to be released but deteriorated with sepsis prior to discharge and the physician again provided critical care, you should report 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for the sepsis treatment rather than billing 99468. This is because the patient is technically still being treated during the same hospital stay and was never discharged.