Pediatric Coding Alert

Initial newborn care codes pay from a high of $868 to a low of $60. Over- or under-charging accusations won't haunt you if you code based on these guidelines.

Take advantage of new code 99477 when a noncritically ill baby requires intensive care services on delivery, the initial assessment day or readmission within 28 days.

Example 1: A pediatrician performs an initial assessment of a newborn and finds the baby has tachypnea (770.6) that requires oxygen, interval checks and monitoring. The E/M service involves work-up for possible sepsis. The physician admits the newborn from the delivery room to the intensive care unit (ICU).

Old way: In 2007, you would have to code this E/M as level-three initial hospital care (99223, Initial hospital care, per day, for the evaluation and management of a patient ...), which pays approximately $174 (4.96 relative value units [RVUs]) using the 2007 Medicare Physician Fee Schedule. Before 99477's creation, when a baby doesn't meet critical care requirements (99295, such as organ system failure) but needs a level of care beyond the acute admissions codes, "we default to a code that has a lesser value than the service being provided," notes Sheryl Forrester, CPC, at Children's University Medical Group in Seattle. "We are trying to apply adult codes and guidelines to these infants, and the coding and documentation requirements don't fit."

New way: On claims dated Jan. 1, 2008, and later, you'll be able to use 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services) instead of 99223. "I appreciate all of the effort being put in to creating codes that better describe the work" my doctors perform with appropriate values, Forrester says.

Payment: CMS recognized the extra work 99477 represents and assigned it 9.30 RVUs (7 work units) for 2008. Using the 2007 conversion factor, 99477 would pay $352. That's $178 more than 99223 pays and $516 less than 99295 pays (approximately $868 for 24.59 RVUs).

When a newborn's condition doesn't require 99477's intensive care services, but still necessitates hospital E/M services, look to 99222-99223.

Example 2: After a pediatrician performs normal newborn care, the infant has a feeding problem that necessitates another E/M service on the same day. An x-ray is normal, and no further interventions are required.

This scenario would require an E/M service that would warrant a mid- or upper-level initial hospital care code, says Richard H. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Because the newborn's condition does not necessitate the intensive services the higher-level code 99477 describes, you would instead use 99222-99223. A baby showing signs of mild tachypnea that doesn't require oxygen would also fall in this category.

Bundle alert: You may code initial care in addition to normal newborn care. So if a pediatrician examines a normal newborn and must re-examine a newborn on the same day, you should separately code the initial history and examination (99431, History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should be used for birthing room deliveries]). You would append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the initial hospital care code (99222-99223) linked to the problem that develops later (such as 779.3, Feeding problems in newborn).

Stay away from the normal newborn care code when a newborn has a minor problem on the initial exam. "Code 99431 is for the examination of a normal newborn only," stresses Donelle Holle, RN, a pediatric nurse with more than 28 years of coding and billing experience for pediatric services. Payers will deny 99431 if you use it with anything other than the normal newborn diagnosis code: V30.xx (such as V30.00, Single liveborn; born in hospital; delivered without mention of cesarean delivery), she reports.

Example 3: A newborn's initial evaluation shows the baby has hypoglycemia (775.6, Neonatal hypoglycemia), which requires early feedings.

You would code an E/M for such a brief symptom with 99221 or 99222, Tuck says. The infant still requires more work than a normal newborn does. Therefore, 99221 and 99222 pay $85 (2.43 RVUs) and $128.47 respectively (3.39 RVUs) compared to $60 (1.57 RVUs) for 99431.

Don't forget: Code 99477 extends to more than just newly born infants before home discharge. The code applies to "neonates discharged to home after birth and readmitted before 28 days of age," points out Richard A. Molteni, MD, FAAP, an AMA CPT advisory committee member.

Tip: When an infant is readmitted and requires intensive services, check his age. If he's 27 days of age or younger, you can code initial care of an intensive illness that requires intensive observation, frequent interventions and other intensive care services with 99477.

Tuck offers this 99477 example: A 2-week-old infant develops fever and irritability that requires readmission with a rule out sepsis workup and close monitoring for the initial day of admission.

Bundles: Look for services included in 99477 in next month's Pediatric Coding Alert.