Pediatric Coding Alert

When weighing an infant is too risky, support 99478-99480 with these steps.

If you're bundling resuscitation with initial intensive care, jumping from normal newborn codes to subsequent critical or intensive care, or omitting weight from subsequent intensive care (SIC) notes, your inpatient coding needs a checkup.

A show of hands at the recent Multi-Specialty National Coding and Reimbursement Conference in Orlando revealed that the majority of coders were not seeing a weight statistic per day on subsequent intensive care charts. "Flipping back a day or days in the chart to code based on the infant's last recorded weight is inappropriate," warned Jill M. Young, CPC, CPC-ED, CPC-IM, with Young Medical Consulting, LLC, in East Lansing, Mich.

Why: You choose subsequent intensive care (SIC) codes (99478-99480, Subsequent intensive care, per day, for the evaluation and management of the recovering ... infant [present body weight ... grams]) based on the infant's present body weight, not birth weight:

• less than 1500 grams -- 99478

• 1,500-2,500 grams -- 99479

• 2,501-5,000 grams -- 99480.

"An auditor would expect to see documentation indicating the infant's weight on that date," Young stresses.

What do you do if weighing the infant would endanger his health? "Many clinical situations could cause this to happen," Molteni says. Here's how he says you can still properly support 99478-99480 in these cases.

Step 1: Let staff know that the note should give the reason the physician says makes it not appropriate to weigh the infant.

Step 2: "Base the weight on the last obtained" measurement, which should be the previous day's record.

When an inpatient normal newborn requires critical or intensive care, make sure you first use an initial:

• critical (99468, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less)

• or intensive (99477, Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services) care code.

Reason: A patient cannot go from regular first (99460, Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) or second day care (99462, Subsequent hospital care, per day, for the evaluation and management of normal newborn) to subsequent critical (99469, Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less) or intensive care (99478-99480). "The subsequent intensive care codes are always used after an-initial day of either 99468 or 99477," says Richard A. Molteni, MD, a neonatalogist at Seattle Children's Hospital.

Work within the critical care (CC)/intensive care (IC) families. For a-newborn who becomes critically ill after receiving subsequent intensive care, "you would use subsequent 99469, not an initial code (99468)," Molteni instructs.

Just because a newborn requires resuscitation in the delivery room, you should not assume the patient will require critical care services. "There are some neonates who do require resuscitation (99465, Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output) including positive pressure ventilation (which might be given by bagging or even intubation), but subsequently stabilize in the resuscitation/delivery room-and do not require admission to a critical care status (99468), but rather an intensive care status (99477) or even well baby nursery (99460)," reports Steven B. Spedale, MD, FAAP, president of Infamedics and Chief of Neonatology at Woman's Hospital in Baton Rouge, La.

Problem: Pediatric Coding Alert, Vol. 11, No 12, states, "Make sure you don't bill 99465 (old 99440) in conjunction with 99477," based on a note following 99465 in CPT 2009. But the AMA's instruction is a mistake.

"This was corrected in the CPT Assistant," says Gilbert I. Martin, MD, FAAP, neonatal intensive care unit (NICU) director at Citrus Valley Medical Center in West Covina, Cal. "Therefore, you can use 99465 with any of the codes including normal newborn. The latter is not a usual clinical scenario."