Pediatric Coding Alert

What to bill when you transfer an infant

Your pediatrician stabilizes a critically ill neonate but has to send the patient to another hospital. If you're wondering what codes to report, you'll need to look carefully at the services the pediatrician provides prior to and during interfacility transport.

Billing neonatal critical care and transport services without duplicating the receiving neonatologist's services is a challenge for many pediatric practices. Which code should I assign when my pediatrician treats a critically ill neonate and then transfers the patient to a neonatal intensive care unit (NICU)-equipped hospital? asks Jan Register, pediatric coding specialist at Pediatric Associates of Anderson (five pediatricians) in Anderson, S.C. Blue Cross Blue Shield (BCBS) denies 99289 (Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24 months of age or less; first 30-74 minutes of hands-on care during transport). "Should I use a different critical care code and, if so, which one?" she asks.
 
Coding experts say the answer depends on which services the pediatrician provides. To improve reimbursement and avoid denials, you should bill based on the following two examples:

Scenario 1: Pediatrician Accompanies Neonate to NICU

During a newborn's interfacility transport, a pediatrician provides critical care services in the ambulance.
 
Because the pediatrician accompanies the patient in the ambulance, you should bill 99289, says David G. Jamiovich, MD, transportation code creator and medical director of pediatric transport program at Hope Children's Hospital in Oak Lawn, Ill.
 
If an insurer, such as BCBS, denies the claim, make sure you assigned the right location code for 99289, says Brenda Wilson, neonatal coding specialist for Mid-Missouri Neonatology in Columbia, Mo. You should use place-of-service (POS) code 41 (Ambulance - land) for land ambulance services and POS 42 (Ambulance - air or water) for air or water emergency transports. In addition, contact BCBS to verify that its computer system contains the new 2003 code: 99289.

For correctly coded claims that the payer still denies, send an appeal letter explaining the circumstances with hospital and/or transport notes, Wilson says.

Scenario 2: Billing for Non-Transport Critical Care

After attending an at-risk delivery, a pediatrician resuscitates the neonate and provides critical care services for 90 minutes until a neonatal team arrives by ambulance to transport the infant to a NICU-equipped hospital.
 
In this case, the transportation team will bill for 99289. Your challenge, however, is to capture all pediatrician-performed procedures prior to transport without using 99295 (Initial neonatal critical care, per day, for the E/M of a critically ill neonate, 30 days of age or less). "Since the neonatologist will bill 99295 for admitting the infant, and insurers won't cover two physicians using 99295 for the same patient on the same day, you should report alternative codes for the services," Jamiovich says.
 
You shouldn't use 99291-99292 (Critical care, evaluation and management of the critically ill or critically injured patient ...) because the notes for critical care services specify that these codes are for patients over 24 months of age, Wilson says.

For the hospital care, you should report 99223 (Initial hospital care, per day, for the E/M of a patient ... physicians typically spend 70 minutes at the bedside and on the patient's hospital floor or unit), which captures 70 minutes of face-to-face services, says Richard A. Molteni, MD, a neonatologist and medical director at Children's Hospital and Regional Medical Center in Seattle. The additional 20 minutes that the pediatrician spends with the infant does not qualify for +99356 (Prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour ...) and +99357 (... each additional 30 minutes ...). But because you used the highest level of E/M service in the initial hospital care category, you may append modifier -21 (Prolonged E/M services) to 99223, he says.

You should also assign 99440 (Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output) for the resuscitation, Molteni says. Because CPT includes 99436 (Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn) in 99440 (resuscitation), don't separately bill for the pediatrician's attendance at delivery.

When the pediatrician provides attendance at delivery and newborn resuscitation, you have a choice of billing 99440 or 99436. Because newborn resuscitation pays more (3.99 relative value units) than attendance at delivery (2.03 RVUs), you should always report 99440 (resuscitation) when you have the option.