Pediatric Coding Alert

The anticipated definition change for 99298 (Subsequent neonatal intensive care, per day, for the evaluation and management of the recovering very low birth weight infant [less than 1,500 gram]) from very low birth weight to present body weight has left many coders wondering which interpretation applies now. Regardless of definition change, experts recommend reporting 99298 for a noncritically ill infant who requires intensive care and whose present body weight is less than 1,500 grams.

Pediatric coders everywhere are asking the same question Patricia S. Wildman, RHIA, clinical reimbursement auditor, Children's Hospital, Boston, is asking. "I realize the American Medical Association (AMA) is clarifying/changing that code in 2003, but have they come out with a correction to the definition that should apply to the use of the code now?" Wildman asks. "If not, 99298 should be used as it is currently defined until the changes are effective in 2003 in order for statistics to be meaningful and consistent." However, coding policy-makers told Pediatric Coding Alert that they always intended 99298 for present body weight.

The intent of 99298 was to have a code that would reimburse the pediatrician or neonatologist for services beyond those the average patient requires, but less than those for a patient who requires critical care, says Joel F. Bradley Jr., MD, FAAP, a member of the AMA CPT advisory committee, and a pediatrician at Premier Medical Group in Clarksville, Tenn. Therefore, it seems appropriate to use present body weight as a basis for coding, rather than birth weight.

When the policy-makers created 99298, they struggled with a way to phrase a definition that would describe the work involved in caring for an infant who is not critically ill but who still needs more care than a normal newborn. They debated about using age, rather than weight. But, gestational age didn't seem to work within these parameters, so the definition states birth weight, Bradley says.

"The key to using 99298 is that the neonate no longer requires critical care but still needs intensive care services, such as cardiac monitoring, checking vital signs frequently and possibly perineteral nutrition," Bradley explains. "CPT states this in its introduction to the neonatal intensive care section: 'Once the neonate is no longer considered to be critically ill and attains a body weight which exceeds 1,500 grams, the codes for subsequent hospital care (99231-99233) should be utilized.' "

"I find it appropriate to code based on the current weight," Bradley says. "99298 is present body weight (not birth weight) specific," agrees Richard Molteni, MD, FAAP, neonatologist and a member of the American Academy of Pediatrics committee on coding and nomenclature, on page 166 of Coding for Pediatrics 2002.

"Anytime the present weight is less than 1,500 grams, it is appropriate to use 99298," Molteni says. "After Jan. 1, 2003, 99299 (1,501-2,500 grams global code) will apply for neonates who weigh more than 1,500 grams but less than 2,500 grams."

However, a neonate who is varying from 1,495 grams to 1,510 grams could drive a coder crazy. "I wouldn't want to see a coder switching back and forth daily between codes," Bradley notes. In most cases, the birth weight should increase. Only in a minority of cases would the infant lose weight. For neonates who are bobbing around 1,500 grams, "use your best judgment," Bradley recommends.

Despite policy-makers explaining that 99298 is for present body weight, Wildman is concerned that carriers may not know the intentions and history behind the code. Insurers may have taken the code at face value, assumed that the definition meant birth weight, and created systems that reflect birth weight. "Payers may have set up edits that would reject 99298 if the birth weight exceeds 1,500 grams," Wildman says. This would mean a computer edit would automatically kick out 99298 anytime the birth weight exceeds 1,500 grams, regardless of whether the neonate fits the care and present weight criteria, she says.

However, the experts do not believe that pediatric practices should worry about this possibility. 99298 was always intended to refer to present weight, Molteni says. Payers, as well as auditors, should understand this.