Pediatric Coding Alert

The new definitions of critical care services (99291, 99292) and neonatal intensive care (99295, 99296, 99297, 99298) pose fresh challenges for pediatricians. They must now compare these codes with the hospital codes (99221-99223 for initial day, and 99231-99233 for subsequent days) and decide which to use.

The news superficially seems to be very good for general pediatricians. The initial neonatal intensive care code (99295) reimburses very well, and most pediatricians should be pleased to know that they can use it under limited conditions. These include: if a baby is 30 days of age or less at the time of admission, you must use 99295 for the first day and the subsequent codes (99296 for critically ill and unstable, 99297 for critically ill and stable, and 99298 for recovering very low birth weight babies).

But due to coding technicalities, many times the general pediatrician is not going to be able to use either the neonatal intensive care codes or the critical care codes. Take the common situation of the pediatrician caring for a recently delivered baby who is critical in a hospital that does not have a neonatal intensive care unit (NICU). The specialist looks after the baby until transport arrives. Heres how coding affects the bottom line: The neonatal intensive care codes are 24-hour codes and can be billed only once per patient per day.

Thus, the original pediatrician cant use 99295 because the receiving hospital will bill it. The pediatrician and receiving hospital cant both be paid for it, and as a general rule, the receiving hospital with the NICU will get paid for it (although technically, health plans pay whichever provider files a global fee first).

Critical Care Codes

The critical care codes are often out of reach as well. The introduction to critical care services in CPT 2000 seems to provide that pediatricians can use them. Critical care services provided to neonates (30 days of age or less at the time of admission to an intensive care unit) are reported with the neonatal critical care codes 99295, 99296, 99297 and 99298. Yes, but only if you are not transporting the child to a NICU.

Richard Molteni, MD, FAAP, says hospital codes offer a path to payment. He is a neonatologist who is a member of the CPT editorial panel and a national expert on coding for the treatment of critically ill newborns. Molteni says the general pediatrician who is taking care of these babies for several hours while waiting for transport should add up the hospital code, prolonged services and the procedures performed. The private pediatrician often will be better reimbursed to bill initial hospital care, prolonged services and all of the procedures that they performed, including delivery room care, he says. But, he warns, If they code 99295, they may not be paid if the NICU at the receiving hospital bills the same code on the same date.

Here are some typical reimbursement dilemmas submitted by Kevin Perryman, administrator of Primary Pediatric Medical Association in Seguin, TX.

Many times our doctors in this rural area will end up having to wait two to four hours for transport to take place. In several instances the babies have been severely critical, requiring very many procedures, including thoracentesis, chest tube, UAC and UVC. Additionally, once the child is stable, he or she still requires constant monitoring by the physician during the two- to three-hour wait for the transport team to arrive. Can all of these codes be billed? And sometimes the baby is stable for 12 to 24 hours but then is eventually transported out. One of the typical patients had respiratory distress syndrome, prematurity and was delivered by C-section. Procedures included attendance at C-section followed by resuscitation including PPV via bag valve mask.

The patient was then stable. The pediatricians time spent on day one was approximately one and one-half hours. But the next day the patient had another episode of respiratory distress syndrome. Resuscitation, thoracentesis, chest tube, umbilical cutdown, UAC and UVC were performed. Time spent on day two was approximately four and one-half hours. We get one of these babies every two to three months.

Perrymans scenarios are not at all uncommon, says Richard H. Tuck, MD, FAAP, founder of the AAPs RBRVS PAC (now called the Committee on Coding and Reimbursement). This is an issue for us too, because we dont keep these babies more than 24 hours, says Tuck, who practices with Primecare Pediatrics in Zanesville, OH. The critical care codes seem more appropriate than the hospital codes for these babies, says Tuck, because the pediatrician is actually doing critical care.

The hospital codes do not accurately describe critical care; the critical care services codes do. And if the neonatal intensive care codesthe other codes that accurately describe what the pediatrician is doing with babies who are criticalcant be used because the receiving hospital will use them, that leaves the general pediatrician in a difficult position. I dont think CPT envisioned this problem, says Tuck.

One of the major objections to Moltenis suggestion to use hospital codes is that many managed care companies do not recognize prolonged services (99356, 99357, 99358, 99359), the only way to bill for all the time spent caring for the baby while waiting for transport.

Prolonged Service Codes

These codes are different from the critical care codes. They are divided between prolonged services with direct patient contact and prolonged services without direct patient contact. And the prolonged service codes would not allow general pediatricians at the originating hospital to take advantage of any of the benefits of the newly defined critical care codes, such as billing for time spent with the family.

Tuck had analyzed the pre-CPT 2000 options for coding critical care for newborns and set up forms that show what combinations of codes would pay the best (individual procedures, neonatal intensive care and critical care services). These charts also can be customized and used to fill in charges paid by a particular insurance plan or state Medicaid plan. The pediatrician can then add up the value of the codes.

These chartseven though they do not account for CPT 2000 changesmake it clear that critical care codes and neonatal intensive care codes are almost always the best option for these cases.

Perrymans second scenario would be billed as follows under CPT 2000:

Day 1: 99440attendance at delivery followed by resuscitation
99223initial hospital care

Time spent: 1.5 hours (patient stable)

Day 2: Respiratory distress syndrome and
pneumothorax
32002thoracentesis with tube insertion
36420umbilical cutdown
36660umbilical arterial catheter, newborn
36510umbilical venous catheter
99233subsequent hospital care
99356 x 3prolonged services face-to-face
99357prolonged services, last 20 minutes

Time spent: 4.5 hours while waiting for transport

If you could bill the critical care codes for this newborn while waiting for transport, the reimbursement picture would be much improved. However, its important that you do bill for every procedure and fight for the prolonged services codes if you have a chance of being fairly reimbursed.

The way CPT 2000 is worded, you probably will just be using the regular hospital codes at the highest level, and then add the procedures prolonged services, agrees A.D. Jacobson, MD, FAAP, editor of the AAPs Coding for Pediatrics and a regional coding trainer for the AAP. But if the timing is right, he says, you could bill the neonatal intensive care codes even if you are transferring the baby out.

Lets say a baby is born at 10 at night, he says. The babys blood pressure goes down and you need to transfer him. The other hospital doesnt get him until after midnight. You can still bill 99295. (Editors note: This is because the receiving hospital's bill for its 99295 will be dated the day after yours, and this code can be billed once per day.)

Jeffrey F. Linzer Sr., MD, FAAP, assistant professor of pediatrics at Emory University School of Medicine in Atlanta, GA, and with the department of emergency medicine at Childrens Healthcare of Atlanta at Eggleston (a major childrens hospital in Atlanta), says that timing is, indeed, key. If a third-party payer receives two bills for 99295, both bearing the same date, theyll deny the second one they receive, he says. But if you are the only one who bills 99295 on a calendar day, you will get paid.

If a baby is born at 2 a.m. and stays until the transport team arrives at 11 p.m., you are pretty much guaranteed of getting 99295, he says. First of all, its highly unlikely that the receiving hospital will even get the baby before midnight. But even if it does, you have clearly provided all but minutes of the care on that calendar day.

Tip: Some insurance companies may allow 99295 to be billed twice on the same day when services are provided by different physicians at different sites, says Tuck.

But it really shouldnt be necessary to have to depend on the timing to decide which code to bill. Jacobson, along with Tuck, feels that it should be possible to bill for the work you doperiod. If I meet the definition for neonatal intensive care code, and I do all the work, I should be paid for it, says Jacobson.

Whenever something new appears in CPT, Jacobson says, there is a period of settlementor sometimes change. This is a new definition, and coding is an art, he says. If youre a pediatrician and you meet the CPT definition of providing critical care or neonatal intensive care services, transferred or not, you should be able to be reimbursed for those services.

If the baby is remaining in your care, this debate is moot: You would charge neonatal intensive care codes. But pediatricians who were used to using the critical care codes for these transfer situations will probably want to stay tuned for more on this discussion.