Pediatric Coding Alert

When in doubt, use the lowest code possible -- that seems to be the philosophy of some insurance companies when it comes to coding for newborns who fall into the gray area between what is normal and what is critical. But is this what is best for you and your practice? Two PCA readers express their frustration with this problem.

What are the appropriate codes for the second level of newborn care? writes Gerald E. Slater, MD, a pediatrician in Glenwood Springs, CO. These children require frequent monitoring, usually oxygen and IV fluid, but usually do not require intubation and prolonged mechanical ventilation. They are not normal newborns, yet they are not the sickest infants either. HMOs regularly try to apply minimal codes to these cases. Whether or not we save the babys life is not as important as saving the economic life of the HMO, states Slater.

And from Dodanim Altamirano, MD, FAAP, of Ville Platte, LA: When a infant is born with some complications but is not critically ill he or she may need IV antibiotics, bili lights, or other services. What code can we use to bill for these services? We cannot use 99431 -- because the infant is not a normal newborn. And we cannot use 99291 or any of those codes -- because the newborn is not critically ill either.

Both readers are articulating what the top pediatric coding experts across the country know all too well -- there is a gap in the newborn codes. In essence, there is no "level two" -- it goes right from level one (99431 for the history and examination of a normal newborn, 99433 for subsequent hospital days for a normal newborn) to the neonatal intensive care codes, which are for critical and unstable infants (99296) and critical and stable infants (99297) only. What is needed is an intermediate code -- for those infants who are not critical, but not normal.

And such a code is, indeed, forthcoming. It has been approved for CPT 99. The RUC has approved a relative value unit of 2.75 for this new code. That recommendation now goes to the Health Care Financing Administration, which accepts the RUCs recommendation for RVUs most of the time. But that is for next year.

How should you code for these children now? Altamirano is absolutely correct in saying the normal newborn codes (99431 and 99433) are not appropriate. And if the child isnt critically ill, you cant use the neonatal intensive care codes either.

The best way to handle this problem is to use the regular hospital care codes. If a child needs extra care the first day, and was therefore not a normal newborn (but not critical), you should use the appropriate code for initial hospital care (99221, 99222, or 99223). Then, you should use the appropriate subsequent hospital care codes (99231, 99232, or 99233) if the problem continued into the next day, or for a problem that surfaced the next day.

Everyone recognizes there is a gap in the way the codes are now, says Richard H. Tuck, MD, FAAP, a coding trainer for the AAP. A child who needs bili lights is no longer a normal newborn, even if the baby was normal at birth. In a case like this -- which is quite common -- you would use the normal newborn code (99431) when admitted. Then, on the day the jaundice develops, you should use the appropriate subsequent hospital code (probably 99232 for jaundice and bili lights only, says Tuck). Incidentally, 99232 has a RVU of 1.55. Obviously, a new newborn code with an RVU of 2.75 would be highly beneficial to pediatricians. Nevertheless, even the 99232 is a higher value than the normal newborn code: 99433 carries an RVU of 1.30.

(Tip: The neonatal intensive care codes -- 99295, 99296, 99297 -- used to be for use in neonatal intensive care units (NICUs) only. However, these codes are no longer location-dependent. The verbiage about NICUs was removed because some babies who were in the NICU werent critically ill, explains Tuck. While many pediatricians still refer to these codes as NICU codes, they are actually critical care codes for newborns.)