EM Coding Alert

Question: My doctor saw a neonate early in the morning. Later that day her condition worsened and she was moved to the critical care unit where another physician within our practice saw her. How do I report these services?

West Virginia Subscriber 

Answer:  Your first doctor would have billed for the initial visit for the neonate. However, when the second doctor saw the patient in the critical care area, presuming he conducted critical services, he would bill a critical care service. 

Doctor A could report 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services) for services relating to the neonate. Doctor B, who is then seeing the infant in critical care, will report from the 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger).

Keep in mind: A physical move from one type of unit to another, in and of itself, does not warrant a change in coding. The type of care the physician delivers to the patient warrants a code change. Also, billing two E/M services in one day may require that you attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) to the second visit or undergo a review of the claim after denial (depending on payer requirements). Your payer may actual require you to combine both services and bill only for an initial service. Always check with your payer in these circumstances.

If your physician transfers a neonate from intensive to critical care and he delivers the critical care, you will report critical care 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger).

You will accumulate your time, the complexity, and all of the various documentation pieces to determine the appropriate level of service.