Pediatric Coding Alert

When a baby is born with some kind of a problem, but the problem isnt severe enough to use the neonatal intensive care codes (99295-99298), should you use the normal newborn care code (99431) for the first examination, or should you use an initial hospital care code (99221-99223)? You cant report bothyou have to choose between one or the other.

This question comes up often, says Kim Rockwell, ART, CCS, CCS-P, coding auditor for Baylor Health Network in Dallas, TX, which has about 20 pediatricians. If an infant is high-risk, but not sick, then they fall into the category of normal, says Rockwell. Its up to the pediatrician to make the decision: Is it a sick newborn, or is it a normal newborn? You dont use the hospital care codes for a high-risk newborn who isnt sick, she stresses.

Fevers

If the baby is sick, you should use the hospital care codes, says Rockwell. But she adds that the diagnosis needs to support the use of the hospital care codes. It could be as simple as a fever, she says.

This question was raised recently at Cumberland Pediatrics, a two-pediatrician practice in Somerset, KY. A baby was running a fever at the time of birth. She was not critically ill, but she was sick, says office manager Joy Campbell. How do I code that? Code 99431 is for a normal newborn.

In fact, fever (780.6 ) is a diagnosis which would warrant the use of the hospital care codes, says Richard H. Tuck, MD, FAAP, who is with PrimeCare Pediatrics in Zanesville, OH. Fevers in newborns usually warrant blood cultures, lumbar punctures, and more, says Tuck, noting that the pediatrician must rule out sepsis. This would be serious enough to use 99222 or 99223, says Tuck. (See descriptions of the hospital care codes on page 31.)

Another problem of newbornsand one which is more common than feversis tachypnea. This warrants a sepsis workup, treatment with oxygen, intravenous fluids, and antibiotics, the pediatrician says. Its definitely not neonatal intensive care, but its also not normal. So for transitory tachypnea of the newborn (770.6), you would use the hospital care codes.

Variations of Normal

Normal is what it says: normal, Tuck stresses. Once a baby does anything that is abnormal, you shouldnt use 99431. But there are variations of normal, which should not warrant a hospital care code. For example, many newborns have certain rashes, such as erythema toxicum [778.8], says Tuck. There are different shapes of the head, or a supernumerary digit. These are not conditions which call for a hospital care code, Tuck believes.

What about jaundice? Jaundice is where it gets ambiguous says Tuck. For the typical physiological jaundice, I would still consider that normal, and use 99433, he says, noting that jaundice would not surface until at least the second day, so he is using the subsequent codes. But for jaundice that requires phototherapy, thats a separately identifiable problem, so I would use either 99231 or 99232. For the infants first day on phototherapy you would use 99232, indicating that there are minor complications, or 99233, indicating a significant new problem or major complication. For the subsequent days, when the infant is stable or recovering, you would use 99231.

Fee Differences

What difference does it make whether you use 99431 or a hospital care code? The reimbursement levels. Normal newborn care (99431) has an RVU of 2.46, with a fee range of $127 to $157, according to the HealthCare Consultants 1998 Physicians Fee & Coding Guide. The first-level admission code (99221) has an RVU of 2.01, with a fee range of $114 to $149. The second-level admission code (99222) has an RVU of 3.27, with a fee range of $151 to $293. And the third-level admission code (99223) has an RVU of 4.20, with a fee range of $184 to $236.

Subsequent days make a big difference, too. Subsequent hospital care for a normal newborn (99433) has an RVU of 1.30, with a fee range of $58 to $73. First-level subsequent hospital care (99231) has an RVU of 1.50, with a fee range of $62 to $78. Second-level subsequent hospital care has an RVU of 1.55, with a fee range of $82 to $101. And third-level subsequent hospital care has an RVU of 2.16, with a fee range of $124 to $154.

Problems on Second Day

Sometimes the newborn seems to have no problems on the first day, and the first exam is coded 99431. But what if the child develops a problem requiring treatment? You no longer use the subsequent normal newborn code (99433); instead, you switch to the subsequent hospital inpatient codes (99231-99233). Using the hospital initial admission codes (99221-99223) would be incorrect for these subsequent days.

What happens if this situation is reversed? The infant is ill on the first day and coded as an admission (99221-99223), but then recovers and is normal on days two and three. You would continue to use the subsequent hospital care codes (99231-99233) for day two and a discharge code (99238-99239) for day three.

Once you leave the normal newborn codes you do not return to them. Likewise, you would not use an initial day hospital care code for the admission of a problem newborn, and then use a normal newborn subsequent care code for the following day once problems had cleared up.

Sometimes a baby develops problems on a subsequent day that are severe enough to warrant intensive care. For example, a ventilator would justify a neonatal intensive care code, says Tuck. Remember that the location where the services are rendered does not mean you would use a particular code. For example, a baby whose condition is critical may warrant the neonatal intensive care codes even in a hospital which doesnt have an NICU, if the services provided warrant such a code, says Tuck. Likewise, you cannot simply put babies with problems in an NICU and use the neonatal intensive care codes. However, these codes do require round-the-clock attendance by a physician, a situation which is unlikely outside of the NICU.

In another scenario, lets say a child on a ventilator in a rural hospital is waiting for transfer. If the pediatrician is attending for several hours while waiting for transfer, the critical care codes would be appropriate.

Finally, if an infant is born in a rural hospital and requires intubation and ventilation (qualifying for newborn resuscitation, 99440), and then several minutes later recovers and transport isnt necessary, the child will be fully stable by the time the pediatrician performs the normal newborn exam, which would allow you to code 99431, as well.