Pediatric Coding Alert

Get them wrong, and your bottom line could be in jeopardy.

The days after a child is born don’t always go smoothly. Sometimes, care of the child can be transferred back and forth between the baby’s pediatrician and a neonatologist, and between the hospital’s nursery, a step-down unit, and a neonatal intensive care unit (NICU).

Such transfers of care create headaches for peds coders, who not only need to determine which codes to use but also who gets to bill them.

These four scenarios cover a number of different situations that could possibly find their way onto your desk someday. Read on and see if you agree with the way our experts have solved them.

Scenario 1: After the child’s birth, the pediatrician examines the neonate and finds that the baby is normal. On day two, the child develops tachypnea and the pediatrician admits the child to the NICU. On day three, the pediatrician reexamines the child and sends the baby back to the nursery.

Scenario solution: In this case, the pediatrician would bill 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) for the exam on day one as the child would be regarded as normal on that day.

Then, things get complicated, and coding the services provided on day two depends on who assumes care of the child and the child’s condition. “If the pediatrician turned the neonate over to the neonatologist, and the neonate was considered critically ill, which required going to the NICU, the pediatrician can bill 99291 [Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes] for the second day of service, based on the amount of time the provider spent with the neonate, and the neonatologist will bill for the admission into the NICU,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

“However, if the baby is critically ill, and if the pediatrician takes care of the neonate in the NICU, the pediatrician can bill the NICU admission code of 99468 [Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger]. But if the neonate required further evaluation and observation and was not critically ill, then the pediatrician would bill 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] for the ill neonate on the second day,“ Holle continues.

On day three the pediatrician would bill 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn), as the neonate no longer has any issues.

Coding caution 1: In this, as in all similar scenarios, failure to code the encounter correctly can lead to some costly mistakes.

“For example, 99460 carries as much as 2.71 relative value units [RVUs] nationwide, while 99468 carries 26 RVUs,” Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts, reminds coders. For 99468, that can mean $937 in lost revenue.

“If you fail to recognize this, your bottom line will be severely impacted,” Walaszek cautions.

Coding caution 2: It’s also important to remember which codes can be billed together. “CPT^® 99460 and 99477, for example, cannot be billed together on the same date,” Walaszek adds.

Simply put, you must make certain you know what service your provider is performing in order to bill the codes correctly. For example, if your pediatrician transfers care of a critically ill infant to the NICU for a neonatologist to take over the care of the child, you cannot bill the 99468 as the neonatologist will be billing that CPT^® code.

Scenario 2: Again, the pediatrician examines the baby on day one and determines the child is normal. On day two, prior to being seen by the pediatrician, the child develops sepsis and is sent to the NICU, which assumes care of the child.

Scenario solution: This time, you will go ahead and still bill the 99460 for your pediatrician’s exam of the neonate on day one. But that’s as far as you can go, as care of the child reverts to the NICU on day two, which will bill 99468 for that day.

Scenario 3: This time, the baby is born with tachypnea and goes directly to the hospital NICU without the pediatrician examining the child. On day two, the neonate’s condition improves, and the child is transferred from the NICU to the regular nursery. At the time, the neonatologist relinquishes care to the pediatrician, who examines the child before discharging the following day.

Scenario solution: On this occasion, “it would be appropriate to bill the normal newborn admission code, 99460, for the second day of birth as this is the first encounter for the pediatrician and the neonate is now ‘normal,’” says Holle.

Additionally, as the pediatrician performs the discharge the next day, he or she will also get to bill 99238 (Hospital discharge day management; 30 minutes or less) or 99239 (… more than 30 minutes) depending on the length of time spent on the discharge.

Coding alert: “Billers should watch this claim carefully as some carriers may determine that only one ‘admission’ code can be used in an admission. Additionally, if the neonate is still having any issue at all, the physician could use 99231-99233 [Subsequent hospital care, per day …] dependent on the history, exam and MDM the provider performed,” Holle notes.

Scenario 4: A 10-day-old infant has been in the NICU since birth due to prematurity and associated problems, but is now stable and ready to move to the step-down nursery. The pediatrician then reviews the records and examines the baby.

Scenario solution: “Depending on the weight of the neonate and whether the child requires further monitoring and observation, the pediatrician can use the subsequent intensive care codes 99478-99480 [Subsequent intensive care, per day, for the evaluation and management of the recovering … infant],” says Holle.

“These codes can be used as long as the neonate is requiring further treatment and should be accompanied by documentation that demonstrates the neonate’s present body weight and what type of monitoring or observation is being performed.

However, if the neonate is just ‘growing and feeding,’ then you should use 99231-99233. Typically, the first visit may be at a higher level, but each day may vary depending on what your pediatrician is doing for the neonate,” Holle concludes.