Pediatric Coding Alert

In the March issue of Pediatric Coding Alert, Richard H. Tuck, MD, FAAP, an AAP coding trainer, answered some tricky questions about newborn coding. The questions were posed by a subscriber, who submitted three reimbursement dilemmas. The subscriber, Thomas J. Catalanotto, MD of Fairfield, OH, specializes in high-risk coverage for a neonatal intensive care unit. The answers led to some more questions from Patricia S. Wildman, RRA, clinical reimbursement auditor at Childrens Hospital in Boston, and explanations from Tuck, who practices in Zanesville, OH. Tuck would not change his recommendations for the first and third scenarios. For the second scenario, his recommendation holds, although there isas often happens in codingan alternate solution.

Scenario One

This involved attendance at a delivery in which there was thick particulate meconium. The infant was intubated two times and meconium was suctioned. Subsequently the infant was fine, and after one hour in the special care nursery for observation, went to the mother. Catalanotto coded this is 99436 for attendance at delivery and stabilization of the newborn, CPT 31520 for laryngoscopy/intubation and suctioning; and 99431 for care of the normal newborn.

Tuck commented that 99436 and 99431 are used properly. However, he suggested using 31500 (intubation, endotracheal, emergency procedure) instead of 31520 (laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn). Since the pediatrician was intubating, not doing a diagnostic procedure, 31500 is more appropriate. 31520 is more for pediatric ENTs, says Tuck.

Wildman would prefer a newborn-specific code (99431normal newborn) in this case. 99436 includes initial stabilization of the newborn, she explains. Since this baby required no oxygen nor IV fluids and was returned to his mom within one hour, it appears this code covers all that was done. I would stay away from the 31500 code category since there are particular codes (99440 and newborn intensive care codes) that include intubation. These comes seem to be more specific for newborns.

Here is Tucks response to Wildmans comments:

I do agree that 99436 includes initial stabilization of the newborn, including resuscitation. It does not, however, include procedures. In this scenario, the infant was intubated with suctioning of meconium. 99440 (newborn resuscitation) does not include intubation, which is appropriately coded separately if done. The neonatal intensive care codes do not include 99440 (newborn resuscitation), but do include endotracheal intubation. This infant clearly does not warrant the use of these intensive care codes.

Scenario Two

This scenario involved attending the delivery of a 29-week premature infant. The baby required resuscitation at delivery, intubation and ventilation, IV fluids, plasmanate for stabilization of poor profusion, and an umbilical arterial line, prior to transfer to a Newborn Intensive Care Unit in Cincinnati. Catalanotto coded the case 99436 (attendance at delivery), 31520 (intubation), and 99291 (critical care codes) until transport.

Tuck agrees with 99436. Again, he recommended 31500 instead of 31520. He also agrees with the use of the critical care codes, but notes that the umbilical line is not included in critical care. Therefore, he would add 36660 (catheterization, umbilical artery, newborn, for diagnosis or therapy).

Wildman thinks 99440 would be better than 99436. Since this baby was vented, it appears 99440 is more appropriate than 99436. I would add the newborn intensive care code 99295 (specific to newborns) rather than the critical care code 99291. Code 99295 includes procedures such as blood vessel catheterization, endotracheal intubation, gastric tube placement, lumbar puncture, mechanical ventilation, surfactant administration, etc. Therefore, codes 31500 an 36660 are not needed.

Jack Percelay, MD, a pediatric hospitalist at John Muir Medical Center in Mill Valley, CA and at the California Pacific Medical Center in San Francisco agrees with Wildman. 99436 should not be used, he says The baby requires resuscitation at delivery, so he should code 99440.

This is one of those cases that shows coding isnt black and white. Indeed, 99440 could be used, says Tuck. This infant received critical care pending transport to the Childrens Referral Center where he or she subsequently would warrant the neonatal intensive care 24-hour global code series (99235-99237). In this situation, I agree that 99440 is a good alternative to 99436, in that, as I noted, the relative value for physician work for 99440 is higher than 99436 (which includes 99440). The use of the 24-hour global neonatal intensive care codes in a setting of infant critical care pending transport to a NICU setting is an arguable point. The other codes (31500 and 36660) are indeed included in the neonatal intensive care codes but are not included in the critical care codes, and, therefore, are justifiably coded separately using the critical care methodology.

Scenario Three

The case involved attending the delivery of an infant of a diabetic. Catalanotto waited for three hours, and was concerned about how he would be reimbursed for that time. When the infant was born, he required ventilation and resuscitation, and Catalanotto spent two hours stabilizing him. He coded the case 99436 for attendance at delivery, and 99255 (consultation).

Tuck recommends using 99440 instead of 99436, which doesnt include resuscitation. The relative value for 99440 is higher than for 99436, and the reimbursement would be higher. Tuck does not agree with the use of the consultation code, but it is only indirectly indicating the services. Instead, he recommends using the critical care codes (99291, 99292). And he reminds Catalanotto to use the hospital admissions code. He recommends 99223, the highest level code.

Wildman and Tuck agree that 99440 is more appropriate because the baby was intubated and vented. Then, the newborn intensive care codes should be used, she says. Once the newborn is no longer considered to be critically ill, then the appropriate subsequent hospital care code should be used. In addition, Wildman would use 99360 six times to capture the standby time (the standby code is in 30-minute increments).

Tuck disagrees with Wildmans use of the newborn intensive care codes. This infant, although critically ill initially, did rapidly stabilize and respond to treatment requiring a defined period of critical care, he says. Although the neonatal intensive care code could be used, it reflects a 24-hour period of critical care for the critically ill infant. I therefore continue to support the use of critical care codes in this scenario.

As for 99360, the standby code, this is still a controversial area. The attendance at delivery code (99436) is a new code, and should replace standby. The reason for its existence is that many insurance companies werent paying for standby. However, some are. In Ohio, for example, Medicaid pays for standby if it is a pediatrician waiting for an infant to deliver (Ohio Medicaid will not pay for other standby situations, however). Pediatric Coding Alert will offer more ifnormation on the difference between these two codes in future issues. Stay tuned.