Pediatric Coding Alert

This directive stops the sending physician from committing an $860 global critical care error.

If both the sending and receiving physician bill for same-day global critical care, you could put your claim on the path to denial -- costing one physician $860 in pay.

CPT 2009 throws neonatal inpatient coding a curve ball. Make sure your transport and discharge reporting skills are up to par with this quiz.

Question: One physician admits a newborn to a hospital. The newborn is then transferred to a different hospital where another physician sees the newborn. Both physicians used 99295.

The insurer paid the first 99295 but denied the second physician's 99295 as duplicate. Does a modifier apply?

Both physicians should not report per diem codes. "The wording in CPT 2009's 'Pediatric Critical Care Patient Transport' notes makes that clear," says Richard A. Molteni, MD, a neonatalogist at Seattle Children's Hospital.

Breakdown: If a physician at a sending hospital provides critical care before the patient is transferred to another facility, the sending physician should use time-based hourly critical care codes (99291, Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes; +99292, ... each additional 30 minutes [List separately in addition to code for primary service]). The physician at the receiving hospital who provides critical care to the patient for the remainder of the day reports the per diem or global critical care code as follows:

• For neonatal critical care, use 99295 in 2008, and in 2009 report 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less).

• For a patient who is age 2 to 5 years of age and requires critical care, report pediatric critical care in 2009 with 99475 (Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child; 2 through 5 years of age).

Here's how CPT's directive applies to critical care services in the same facility but in different settings:

• If a physician provides critical care services to a patient in the emergency department (ED), which is an outpatient setting, and then a different physician in another group admits the patient to critical care, the physician providing the services in the ED would bill the hourly critical care (99291, +99292) and the admitting physician in another group would bill the global critical codes (99468, 99475).

• If the same physician provides outpatient and inpatient critical care in both settings, report only the global care code for all critical care services the physician provides that day.

Reason: No two physicians can both claim same-day per day critical care, which 99295/99468, 99475 represent, for the same time period or day. Experts have long recommended following these same coding principles to avoid insurers rejecting the receiving physician's global service (23.84 relative value units [RVUs] for 99468 or approximately $860 using the 2009 Medicare Physician Fee Schedule) as duplicate.

Action: Refile the sending physician's claim with 99291 and possibly +99292 (based on time). You should be able to determine the critical care minutes the physician provided to the newborn using the chart notes.

Question: A pediatrician saw a well newborn for routine care and reported 99431 (2009 code: 99460, Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant)
for the first day of care and 99433 (2009 code: 99462, Subsequent hospital care, per day, for the evaluation and management of normal newborn) for the second day of care.

On the discharge day, the newborn had a significant sounding heart murmur, and when his facial bruising and swelling subsided, he looked a little like a trisomy 21. The pediatrician ordered a work-up that included taking oxygen saturations, four extremity blood pressures, and an echocardiogram, and obtaining karyotype. These tests' results did not preclude the physician from discharging the newborn that day. The pediatrician had lengthy discussions with the parents. Can I code for anything else besides 99239 (Hospital discharge day management; 30 minutes or less)?

Unfortunately, 99239 is it, says Victoria S. Jackson, practice management consultant with JCM Inc. and former administrator/CEO of Southern Orange County Pediatric Associates Inc. in California. "I looked at all appropriate codes for visits and discharges -- including critical care codes -- and because the physician sent the baby home the same day, nothing I looked at worked."

For instance, you can't use prolonged service codes (99356-99359) because the discharge codes do not contain a specific time allotment. Code 99238 is for "30 minutes or less" and 99239 is for "... more than 30 minutes." There's no way to count an hour beyond the time included in open-ended 99239.

You also can't use a subsequent hospital care code (99231-99233) on the same day as a discharge code. "The subsequent hospital visit codes should not be reported on the day of discharge either alone or in addition to the discharge code," according to Coding for Pediatrics 2009.

As for the procedures, hospital staff will perform the work-up procedures, such as multiple oxygen saturation determinations (94761, Noninvasive ear or pulse oximetry for oxygen saturation; multiple determinations [e.g., during exercise]). If your pediatrician interprets the ECG and issues a report, bill 93010 (Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only) for the professional component.