Pediatric Coding Alert

Many neonatologists and pediatricians struggle with the nuances of switching among age-based critical care codes. But remembering the neonate-to-pediatric milestone will ensure that coders and physicians submit audit-proof claims.

You probably anticipated, as many pediatric coders did, that the creation and revision of 99293-99296 would streamline neonatal and pediatric critical care coding. But many experts find that the new and revised codes require a thorough knowledge of the age-specific definition. Questions arise mainly when a patient transitions from 30 to 31 days of age, and from 24 months to greater than 24 months of age, says Joel F. Bradley Jr., MD, FAAP, American Academy of Pediatrics CPT adviser. These great divides from neonate to pediatric and older child to adult require code shifts, which is where understanding the intricacies of the new CPT Codes becomes important.

Get out of Town at 31 Days

The first hot spot occurs when a neonate remains critically ill past 30 days of age. When a pediatrician treats a critically ill neonate who changes from 30 to 31 days of life, you should choose the code based on the patient's age neonate or pediatric.

The age change from 30 to 31 days of life requires you to shift from neonatal critical care codes (99295, Initial neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less; and 99296, Subsequent neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 30 days of age or less) to pediatric subsequent critical care (99294, Subsequent pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child).

CPT considers the care subsequent because the neonatologist has already provided care to the patient. Do not fall into the trap of thinking that because you have not reported a pediatric critical care code for the patient that you should assign initial pediatric critical care (99293, Initial pediatric critical care, 31 days up through 24 months of age, per day, for the evaluation and management of a critically ill infant or young child).

"The advent of new pediatric critical care codes makes the transition from subsequent neonatal critical care to subsequent pediatric critical care very clear," Bradley stresses.

Abolish Old Methods

This transitional coding may fly in the face of previously held coding tenets. Before 2003, you could continue to use the same neonatal critical subsequent care code (99296 or 99297) beyond 30 days of age as long as the patient's care was provided during a single episode of critical care, Bradley says.

The creation of the new pediatric critical care codes requires a coding shift. For a critically ill neonate who turns 31 days of age while still receiving critical care, you will now report the subsequent pediatric critical care code (99294), he says.

Neonate-to-Pediatric Made Clear

Let's look at a scenario to pinpoint how this transitional coding should work. Consider a neonatologist who is attending a 700-gram preterm newborn admitted to the neonatal intensive care unit (NICU) with hyaline membrane disease, persistent pulmonary hypertension of the newborn, meconium aspiration syndrome, and bronchopulmonary dysplasia on an oscillator. The neonate remains critical for his first 35 days of life.

For the first 30 days, you should use the neonatal critical care codes, says Richard A. Molteni, MD, FAAP, a neonatologist with Children's Hospital & Regional Medical Center in Seattle. Report 99295 for the initial day and 99296 for each subsequent day, for a total of 29 days.

When the infant is 31 days old and still critical, the neonatologist continues to provide care to the patient. Therefore, you should report subsequent pediatric critical care code 99294 starting on the patient's 31st day, even though it is the first time that you are reporting a pediatric critical care code, Molteni stresses.

Incoming Holds True

Now, transitional coding presents one more problem. When a pediatrician assumes care for a patient who is already receiving critical care services, uncertainty rises regarding whether the pediatrician provides initial or subsequent care. "Code 99293 does not refer to the first day of life or an illness," Molteni says. "Initial" means the work involved in admitting the patient.

For instance, Hospital A transfers a critically ill infant who is 31 days old to Hospital B. It is the first time during this session that the pediatrician at Hospital B provides critical care to the infant. Therefore, you should report initial critical care code 99293 for the day of admission. Assign 99294 for the subsequent days as long as the infant remains critical.