Pediatric Coding Alert

When a neonate changes from a normal to sick, you risk overlooking opportunities to bill for all the services you performed. To avoid such oversights, follow these seven steps to reimbursement success.

Hospital setting: If a newborn is normal, you should report the standard newborn codes. For the first examination, use 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]). For each subsequent day, assign 99433 (Subsequent hospital care, for the evaluation and management of a normal newborn, per day). Because 99431 and 99433 are per-day codes, you may bill them once per day only, regardless of how often the doctor sees the infant.

Office setting: When the pediatrician sees the baby for the first time and the visit occurs in the office, use an office visit code (99201-99205) or preventive medicine services code (CPT 99381 ). If she has been seen previously in the nursery, the infant is an established patient (99211-99215).

When a pediatrician attends a birth, opportunities may exist to bill more than 99436 (Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn). If the pediatrician performs positive pressure ventilation and/or chest compressions, you should report the resuscitation code 99440 (Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output), says Richard A. Molteni, MD, FAAP, vice president, medical director, Children's Hospital & Regional Medical Center, Seattle. When both 99436 and 99440 are furnished, CPT states you can use only one of these codes. You should choose 99440, because it pays more than 99436.

If the pediatrician performs intubation (31500), laryngoscopy with aspiration for meconium (31515), or places an umbilical venous catheter (36510), you should bill these in addition to 99440, Molteni says.

A baby may appear normal at birth, then several hours later develops a problem that is not serious enough for critical care but moves the baby out of the normal category. For example, after attending a delivery, suppose the pediatrician examines the baby and finds he is normal. Then, the baby develops tachypnea at four hours of age and requires attention as a sick infant.

For day one, code initial hospital care (99221-99223), not normal history and examination (99431),says Richard H. Tuck,MD, FAAP, chairman of the American Academy of Pediatrics' task force on reimbursement and pediatrician at PrimeCare of Southeastern Ohio in Zanesville.

If you perform any procedure, e.g., obtain a blood specimen (36406) or perform a lumbar puncture (62270) or suprapubic bladder aspiration (51010), bill these as well. Procedures are not bundled into the hospital care codes, Tuck says.

To report neonatal intensive care codes (99295-99298), you must document organ failure or acute life-threatening disease. These codes may be billed daily and include almost all procedures you might perform on a critically ill newborn.

The first time a newborn requires critical care within the first 30 days, you should use 99295 (Initial neonatal intensive care, per day, for the evaluation and management of a critically ill neonate or infant). Any critically ill infant admitted or readmitted within the first 30 days of life qualifies for neonatal intensive care codes.

Many babies in the neonatal intensive care unit (NICU) may not qualify for 99295-99298. Although each of the following criteria may warrant the hospital care codes, or 99298 (Subsequent neonatal intensive care, per day, for the evaluation and management of the recovering very low birth weight infant [less than 1500 grams]), they do not support using neonatal intensive care codes: