Pediatric Coding Alert

In the April issue of PCA (page 30), we discussed how to code newborn days in the hospital if the baby is not normal, but not sick enough for the neonatal intensive care codes (99295-99298). The answer, as we reported, is to use a mix of normal newborn care (99431 for the initial examination, 99433 for subsequent days) and hospital care (99221-99223 for the first or admission day, 99231-99233 for subsequent days). But exactly what mix you choose may depend, at least partially, on reimbursement rates.

RVU Update

The RVU (Relative Value Unit) scale is important here, because it reflects fee differences. Take the case of a baby who is sick enough the first day to be admitted using CPT 99221 (initial hospital care, per day, for the evaluation and management of a patient which requires these three key components: a detailed or comprehensive history; a detailed or comprehensive exam; and medical decision-making that is straightforward or of low complexity). But on the second day, the baby has recovered. Should you go back to 99433 (subsequent hospital care for a normal newborn) or stick to the first level of hospital care codes 99231 (subsequent hospital care, lowest level)?

Consider the RVUs. In 1999, the RVUs for 99433 went down to 1.23 from 1.30 in 1998, and for 99231 went down to 1.04 from 1.50 in 1998. For 99232 (subsequent hospital care, second level), the RVU is 1.56. According to the Healthcare Consultants of America 1999 Physicians Fee & Coding Guide, 99231 pays a range of $64 to $81, 99232 (if the patient is not stable but has a minor complication) pays $84 to $103, and 99433 pays $67 to $83. So, you are likely to get reimbursed slightly more for the normal newborn code than for the lowest level subsequent hospital code.

Its fine to move either way between the normal newborn codes and the sick hospital codes, says Richard H. Tuck, MD, FAAP, of PrimeCare Pediatrics in Zanesville, OH. If the baby is sick on the first day, and better on the second, its okay to go back to normal newborn at that point. On the other hand, you can stick with the sick hospital codes, using the lowest level, if you prefer. It really depends on the reimbursement from your carriers. As you can see from the fee ranges, they are very close.

If you do use 99231 on the second day for a baby who is now stable, but was sick enough to admit using 99221 on the first day, what diagnosis code should you use? Typically, you should use only one diagnosis code for the entire hospitalization, explains Tuck, who is also the representative for the AAP to the AMAs RBRVS Review Update Committee. That means that you should stick with the diagnosis code you used to admit the baby on day one.

Tip: If, however, a consultant is called in to see the child, a different diagnosis code should be used, says Tuck. Its important for physicians to use different diagnosis codes if they both see the same patient on the same day, he adds. Insurance plans dont want to pay two physicians for taking care of the same problem.