Pediatric Coding Alert

Tip: Separate site warrants separate pay

If you don't know the exceptions to the critical care bundles, you could be under-reporting neonatal services and procedures.

Test yourself by coding this scenario submitted by Pamela J. Dirickson, coder with Neonatology Cox Health in Springfield, Mo.:

A doctor attended a delivery of a 28-week gestation baby. The infant received positive pressure ventilation (PPV) in the delivery room (DR) with mask and bag for absent respiratory effort at birth. The baby was then intubated in the delivery room and received PPV on transfer to the neonatal intensive care unit (NICU) where mechanical ventilation was initiated.

"Can we charge 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 in the delivery room and 31500 intubation in the delivery room as well as 99295 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less) for the admit to the NICU?" she asks.

"I have received advice that would have me use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service), 51 (Multiple procedures), and/or 59 (Distinct procedural service) with these charges. What is the correct billing at this time?"

Use these steps to determine what codes to bill in addition to 99295.

1. Bill 99436/99440 Separately From 99295

When coding resuscitation with initial neonatal critical care, you should always remember one rule: "Newborn resuscitation services (99440) may be reported in addition to 99295," says Darlene Ornburn, MBA, CPC, CCP, in her presentation "Taking the Crisis Out of Critical Care Coding." That means, in the above scenario, as well as anytime a pediatrician attends a delivery and provides resuscitation, you should report both 99440 and 99295.

Be careful: Although the pediatrician attends the delivery, you should not also report that service. "Do not report 99436 in conjunction with 99440," according to CPT's parenthetical instruction following 99436.

Modifier: No bundle exists for 99440 and 99295. In 2004, CMS deleted the code edit for 99440 and 99295. Therefore, no modifier should be necessary when reporting this pair. The Georgia Chapter of the American Academy of Pediatrics lists 99440 (newborn resuscitation) with 99295 as "examples of services performed on the same date of service that do not require a modifier."

Similarly, you may report 99436 (attendance at delivery) with 99295 (initial inpatient neonatal critical care) or 99431 (initial normal newborn care) without a modifier. Some insurers, however, may want modifier 25 on 99295 to indicate the critical care -- or on 99431 to indicate the initial newborn care -- is a significant, separately identifiable service from the resuscitation (99440).

2. Code Necessary Preadmit Procedures

In your case, you can also report the endotracheal intubation in addition to the resuscitation and neonatal inpatient critical care. When your pediatrician performs resuscitation-related procedures as part of the pre-admission delivery care, the procedures aren't included in the global codes. Inpatient code 99295 does not include medically necessary procedures done in the delivery room, says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio.

Normally, initial inpatient neonatal critical care (99295) includes procedures such as endotracheal intubation (31500, Intubation, endotracheal, emergency procedure). But these bundles reflect inpatient services performed as part of critical care management.

Exception: When these services are medically necessary in the delivery room prior to admission, the procedures are exempt from the bundle. "The initial-day neonatal critical care code (99295) can be used in addition to codes 99360, 99436, or 99440 as appropriate, when the physician is present for the delivery (99360 or 99436) and newborn resuscitation (99440) is required," states the AMA in the introductory notes to the "Inpatient Neonatal and Pediatric Critical Care Services" subsection. "Other procedures performed as a necessary part of the resuscitation (for example, endotracheal intubation [31500]) are also reported separately when performed as part of pre-admission delivery room care."

Caveat: To report these procedures separately, the physician must perform them as a necessary component of the resuscitation and not simply as a convenience before admission to the neonatal intensive care unit (NICU), the AMA stipulates.

3. Use 59 to Indicate Separate Site

You may report medically necessary delivery-room procedures in addition to inpatient critical care services because the care occurs at different sites of service. That's what makes preadmission procedures distinct procedural services from inpatient critical care.

Action: To indicate the pediatrician performs the intubation at a separate site from the critical care, you should append modifier 59 (Distinct procedural service) to the delivery-room procedure: 31500-59.

"The National Correct Coding Initiative (NCCI) edits permit you to append modifier 59 to 31500 (column 2 code) to 'unbundle' it from 99295 (column 1 code)," says Brenda L. Wilson, president of Med Charge Inc., which handles claims filing for Mid-Missouri Neonatology LLC. This modifier is allowed when it is medically necessary for the intubation to be performed prior to admission to the NICU, she says.

Tip: Make sure hospital delivery and admit notes support the separate sites of service and procedure. Notes should "document the medical necessity of the intubation being performed in the delivery or operating room before the infant is transported to another area of the hospital where the NICU is located," Wilson says.

Be careful: Check with major payers for their modifier 59 policies. For instance, Missouri Medicaid wants claims containing 99295, 99440 and 31500 without any modifiers, Wilson says.