Pediatric Coding Alert

When a newborn requires certain procedures to be performed by the pediatrician who is at the delivery, but then the newborn is transported to another facility, how should the pediatrician bill for the time involved? Georgia Greenhill, from the office of Susan B. Chamberlain, MD, a pediatrician in Trenton, MI, has been having problems getting reimbursed for all of the procedures done in such cases. The following scenario is typical: Chamberlain attended an emergency c-section for an abrupted placenta. She performed resuscitation with positive pressure breathing, endotracheal intubation, and laryngoscopy for aspiration. She then spent an hour attending the baby, waiting for the transport team to arrive. Blue Cross wont pay for all of the procedures, says Greenhill.

Stabilization vs. Attendance

Most insurance companies will not pay for each of these procedures separately, so billing for the encounter is a matter of choosing the best-paying combination of codes, explains Donelle Holle, RN, reimbursement specialist for the Department of Pediatrics at the University of Michigan Health System. If you are attending a delivery and doing a resuscitation, then you need to look at reimbursement, she says. For attendance at delivery and resuscitation, you can only use one code, she explains.

Attendance at delivery is code 99436 (attendance at delivery [when requested by delivering physician] and initial stabilization of newborn), which is to be used when the obstetrician requests the pediatrician to be present. Since 99436 is also for initial stabilization of newborn, resuscitation is considered bundled into the attendance-at-delivery code, says Holle. However, newborn resuscitation would be the best code to use in Chamberlains scenario. But in order to use 99440 (newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output), you must provide either positive pressure ventilation, chest compressions, or both. You cant bill both 99436 and 99440, says Holle. CPT Codes even states that 99436 may not be reported in addition to 99440.

Noting that carriers pay better for 99440 than for 99436, Holle says that when positive pressure breathing or chest compressions are required, the pediatrician should definitely code 99440 and not 99436.

But many newborns are resuscitated by positive pressure ventilation only. And 99440 doesnt cover endotracheal intubation; it covers positive pressure ventilation and/or chest compressions. The ET tube is not bundled into the procedure.

Coding for Other Procedures

What about the other procedures done by Chamberlainpositive pressure ventilation (94652, with or without nebulized medication), endotracheal intubation (31500, emergency procedure), and laryngoscopy for aspiration (31515, with or without tracheoscopy)? The only one of these that you will be able to properly bill for is 31515, Holle says.

An ET tube is standard for resuscitation, so they wont pay for that in addition to 99440, explains the reimbursement specialist, who used to be a charge nurse and helped at all emergency c-sections. If youre going to have a true resuscitation, youre going to have to do an intubation.

The same is true of positive pressure breathing. By definition, positive pressure ventilation is included in code 99440.

However, laryngoscopy for aspiration is definitely a separate procedure from standard resuscitation, says Holle. The doctor may need to see whats going on further down, she explains. There may be meconium farther than the ET tube can go. Therefore, Chamberlain should be paid separately for the laryngoscopy, Holle says. You might need a -59 modifier to indicate that this is a distinct procedural service. But you should definitely file for it and be paid for it. Laryngoscopy is not standard with resuscitation.

Waiting for Transport

The hour spent waiting with the child for the transport team to arrive should be coded 99295 (initial neonatal intensive care). If, however, the payer covers two critical care services on the same day, you should bill the critical care code (99291-99292), and then the receiving hospital would bill 99295.

To bill the critical care codes, the child must be unstable and critically ill. During the hour you are with the infant, you are monitoring constantly. The critical care codes include ventilator management, which you will probably be performing, as well as vascular access procedures. However, they do not include the laryngoscopy if you need to suction out meconium again during the critical care period, notes Holle.

The timing of critical care codes is a bit complicated. The first hour is actually from 30 to 74 minutes, which is code 99291 (evaluation and management of the unstable critically ill or unstable critically injured patient, requiring the constant attendance of the physician; first hour). For each additional 30 minutes, you would use 99292 (list separately in addition to code for primary service). Note that the time spent on critical care does not need to be continuous. If, for example, you leave the child for five minutes with a nurse while you talk to the mother in her room, you note the time you are leaving in the chart. When you return, note the time again. By using the time-in, time out method, you can keep track of whether you spent enough time to bill for the first hour (which is really a minimum 30 minutes of total critical care).

Prolonged services codes would be used if the child were stable, says Holle. These are also timed codes, and you can use the time-in, time-out method. However, these are add-on codes, which means that they must be listed in conjunction with the other E/M services codes. In this case, the prolonged services codes would be added on to the 99440 resuscitation code. For the first hour (30 to 74 minutes), you would code 99356 (prolonged physician service in the inpatient setting, requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high-risk delivery or other physiological monitoring, prolonged care of an acutely ill inpatient]; first hour. [List separately in addition to code for inpatient Evaluation and Management service.]) For each additional half hour, you would code 99357.

Editors Note: For more information on prolonged codes, see page 23 of the March issue of PCA.

Diagnosis Coding

The diagnosis codes used by Greenhill for Chamberlains case are 641.2 (premature separation of placenta), 765.1 (preterm infant), 769 (respiratory distress syndrome), and 762.1 (fetus or newborn affected by complications of placenta, cord, and membranes; other forms of placental separation and hemorrhage). The order of these diagnosis codes on the HCFA 1500 form, as well as the correct application of additional digits, are both very important to prompt and accurate payment, Holle explains.
While 641.2 is correct, this diagnosis should actually be used only on the mothers chart. The diagnosis of respiratory distress syndome (769) should be the primary diagnosis on the newborns chart, followed by 762.1 second, and 765.1 third. The diagnosis of 762.1 is much better than 641.22 anyway, since you are coding specifically for the childs record and claims.

Note: With code 765.1 (disorders relating to short gestation and unspecified low birthweight; other preterm infants), you are required to use a fifth digit denoting birth weight. Code 765.0 is for extreme immaturity, and implies a birth weight of less than 1000 grams and/or a gestation of less than 28 weeks, while 765.1 is for other preterm infants, and usually implies a birth weight of 1000 to 2499 grams, and/or a gestation of 28-37 weeks. The birth weight fifth-digit classifications are as follows: 0 (unspecified), 1 (less than 500 grams), 2 (500-749 grams), 3 (750-999 grams), 4 (1,000 to 1,249 grams), 5 (1,250-1,499 grams), 6 (1,500-1,749 grams), 7 (1,750-1,999 grams), 8 (2,000-2,499 grams), and 9 (2,500 grams and over). If the infant in Chamberlains case weighed 1,900 grams, the correct diagnosis code would be 765.17.

Then you need to match the diagnosis codes with the correct procedure codes. The diagnosis of respiratory distress syndrome (769) should be matched with newborn resuscitation (99440). The other diagnosis codesfetus or newborn affected by complications of placenta, cord, and membranes; other forms of placental separation and hemorrhage (762.1) and preterm infant (765.1x)should be matched with the critical care codes (99291, 99292) or the prolonged services codes (99356, 99357), whichever you decide to use.