Pediatric Coding Alert

Many pediatricians and payers are confused about what additional services can be billed when coding for attendance at delivery (99436, Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn). If you include too many additional services, you can be accused of coding fraudulently, and if you code too few you are losing money.

Resuscitation in Addition to 99436

Some think that resuscitation code 99440 (Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output) includes intubation. However, that is not always the case. For neonatal resuscitation, as described by 99440, resuscitation does not automatically include intubation, although in the delivery room intubation would usually involve resuscitation.
 
Code 99440 involves positive pressure ventilation a bag and mask says Richard Molteni, MD, FAAP, a neonatologist and medical director of Children's Hospital and Regional Medical Center in Seattle. "This does not require an endotracheal tube," Molteni says. "If the endotracheal tube is used, it should be reported separately using 31500 (Intubation, endotracheal, emergency procedure)."
 
Note: Intubation in the delivery room usually means resuscitation, but it doesn't necessarily mean ongoing ventilation. Babies who are intubated and put on the ventilator are always critical care. (See coding for critical care below.)
 
You should use 99436 (attendance at delivery) for a newborn that does not require positive pressure ventilation or chest compression. Teri Salus, health policy specialist with the AAP division of healthcare finance and practice, says 99436 includes drying, stimulation, suctioning and blow-by oxygen. Code 99436 is for attending any delivery (whether the baby is normal or not) except one in which the pediatrician resuscitates the newborn. In that case, use the resuscitation code (99440) instead of 99436.

Proper Coding When Baby Is Critical

"When a newborn needs intubation at delivery, by definition the baby is critical," says Charles J. Schulte III, MD, FAAP, an AAP representative to the AMA CPT Codes advisory committee and practicing pediatrician in Washington, D.C.
 
Newborn critical care should be reported with 99295 (Initial neonatal intensive care, per day, for the evaluation and management of a critically ill neonate or infant). This can be billed in addition to the attendance at delivery (99436) or resuscitation (99440).
 
If you intubate a newborn, you should not code 31500 with 99295, because critical care includes intubation. However, if performed, you can report laryngoscopies (31515, Laryngoscopy, direct, with or without tracheoscopy; for aspiration; 31520, ... diagnostic, newborn) with neonatal care (99295). Based on the case, you may also bill resuscitation (99440) or attendance at delivery (99436).
 
But there are rare circumstances in which a baby would require intubation but not be critical. "Some babies require resuscitation and intubation in the delivery room, but can then be quickly extubated and put in oxygen," says Richard H. Tuck, MD, FAAP, founding chairman of the AAP coding and reimbursement committee. "It's true that the majority may end up being considered neonatal critical care, but not all," says Tuck, who practices with PrimeCare of Southeastern Ohio in Zanesville, Ohio.
 
In a hospital with a neonatal intensive care unit, the staff neonatologist would likely be attending the birth and performing the intubation. The neonatologist would bill 99295 if the baby is critical.
 
The most likely times to bill resuscitation (99440) and intubation (31500) together are when the pediatrician:

 1. is going to transfer the baby to another hospital on the same date and wants the receiving physician to be able to bill 99295, a daily code

 2. attempts to revive a baby with a bag and mask or chest compressions (99440) and it doesn't work, and the pediatrician then moves on to intubation (31500).

Coding for Inspection for Meconium

Sometimes a pediatrician is called to attend a delivery because the obstetrician notices meconium in the fluid. A variety of coding scenarios can occur during this process:

 1. The pediatrician uses a laryngoscope to visualize the vocal cords to determine whether meconium has entered the lungs, but the newborn is not intubated. In this instance, you should code the attendance with 99436 and the laryngoscopy with 31520 ( diagnostic, newborn).

 2. A baby is born with thin meconium that requires oropharyngeal suctioning. Because there is no code for suctioning, you can only bill 99436.

 3. If the baby requires resuscitation by positive pressure ventilation (bag and mask) or chest compressions, you should bill 99440 instead of 99436 (remember, these codes cannot be billed together based on CPT).

 4. If the meconium is thick and the trachea must be intubated and suctioned, code 31515 with 99436.

 5. If the trachea must be suctioned and the baby requires chest compressions or positive pressure ventilation (bag and mask), bill 99440 with 31515.

 6. If the baby must be intubated for ventilation, bill 31500 with either 99436 or 99440.

 7. If the baby is fine after the intubation and suctioning, is extubated, and subsequently normal, also bill 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]) for examining the baby later, because this is now a normal newborn, Tuck says.