Pediatric Coding Alert

Level of care key when documenting newborn illness.

If you've been a peds coder for any length of time, there's a good chance you've become familiar with this particular scenario: a sick neonate is admitted to the hospital for evaluation and management (E/M). Your provider documents a level of care that is not critical, so you immediately - and correctly - rule out 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger).

Instead, you reach for 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services). But is that always the right choice?

We asked our experts, and here's what they said.

Know When to Use 99477

Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, feels that 99477 is the appropriate choice "when a baby is ill, but not critical, and the neonate requires frequent monitoring and more interventions but less than a critically ill neonate." In other words, Holle says, "99477 babies typically are moved from critical care to either a stepdown unit or the Neonatal Intensive Care Unit (NICU)."

Holle's position is shared by Jana A. Stockwell, MD, FCCM, and Marvin N. Hall, MD, CPE. Writing in Critical Connections, the Society of Critical Care Medicine's news magazine, Stockwell and Hall maintain that, "for neonates younger than age 29 days who are not critically ill but who nevertheless require intensive observation, frequent interventions, or other intensive care services, 99477 is the appropriate middle-tier initial hospital care code" (Source: http://www.sccm.org/Communications/Critical-Connections/Archives/Pages/Coding-for-the-Pediatric-Patient.aspx).

Know How to Use 99477

Once your provider decides that intensive care is appropriate for the neonate, you'll need to pay careful attention to your documentation. Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania, directs coders to the CPT^® guidelines, which outline the kinds of monitoring and observation involved in this level of care that you will need to record.

The guidelines include "intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the health care team under direct supervision of the physician or other qualified health care professional."

Importantly, Falbo goes on, your provider "does not have to be present 24/7 to perform these procedures or services." Instead, Falbo continues, the pediatrician must "directly supervise everyone involved in the neonate's care and provide careful review of the care plan."

And Know When 99477 Isn't Appropriate

But, Stockwell and Hall go on, "infants who do not require even this degree of intervention or monitoring should be coded as routine initial [99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...)] or subsequent [99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...)] hospital care as appropriate."

Holle elaborates with the following examples: "99222 would be a baby that stays in the regular nursery but requires more testing like labs, x-rays, or work not typical for a normal newborn neonate [NBN]. Likewise," Holle continues, "this could be a baby where a significant heart murmur is heard or that has other issues, such as low blood sugar or not being able to keep their temperatures up, where x-rays, labs or even consultations are required."

And, Falbo reminds coders, you would also use these codes for children "older than 28 days and more than 5000 grams." Additionally, coders may also need to switch back and forth between the codes to most accurately describe the neonate's situation. So, Falbo continues, a baby classified normal at birth could develop a condition like jaundice on the second day of life. "This would require a switch to a code such as 99222," Falbo says, "and, if the condition has significantly decreased by the third day, you could go back to the normal newborn codes again."

The Bottom Line

The difference between 99221-99223 and 99477 is further reflected by the difference in the current Medicare facility/nonfacility fees and total relative value units (RVUs) for the services. So, while 99221-99223 are valued at $193.32 – $206.64 (2.87 – 5.74 RVUs), 99477 is valued at $355.68 with a total RVU value of 9.88. Or, as Holle concludes "there are many neonates who are not critical or even need constant monitoring but require much more 'work effort' on behalf of the physician than seen in what is considered a normal NBN initial visit."