Pediatric Coding Alert

A newborn's condition can change from normal to sick to normal again before the infant leaves the hospital. Accurately coding these transitions in the health of neonates depends on carefully monitoring and reporting the progression of services a pediatrician provides for the neonate until the patient is ready to go home.

Normal Newborn Stays Well:Report Newborn Care Codes

If, after examining a newborn in the hospital nursery, the pediatrician determines that the baby is normal, you should report 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 the initial examination, according to CPT.

For each subsequent day the physician provides care for the normal neonate in the hospital, assign 99433 (Subsequent hospital care, for the evaluation and management of a normal newborn, per day). Because 99431 and 99433 are per-day codes, you may bill them once per day only, regardless of how often the pediatrician sees the infant, coding experts stress.

CPT Codes also specifies that when the physician admits and discharges the neonate from the hospital or birthing room on the same day, you should use 99435 (History and examination of the normal newborn infant, including the preparation of medical records [this code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date.])

Moreover, code 99435 also applies to same-day initial examinations and discharges when a baby delivers at night and the pediatrician initially examines it the next morning and discharges that evening.

If the physician discharges the newborn on a subsequent day after it is admitted, CPT states that you should report 99238 (Hospital discharge day management; 30 minutes or less) when the discharge services, such as giving instructions for care, take 30 minutes or less to complete.

If discharge services take 30 minutes or longer, such as when an infant has been ill and the doctor spends extra time coordinating care or when an anxious mother with many questions requires extra time, report 99239 ( more than 30 minutes), says Richard Tuck, MD, FAAP, practicing pediatrician with Primecare Pediatrics of Zanesville, Ohio. These discharge codes are day codes and apply to all services performed on that day. Because these are also time-based, document the time spent in the patient's record if greater than 30 minutes, Tuck says.

Well Newborn Gets Sick:Report Hospital Care Codes

Often, a newborn will appear normal at birth but will develop a problem such as jaundice (774.6), tachypnea (770.6), or polycythemia (776.4) a few hours later that is not serious enough for critical care but moves the baby out of the "normal" category.

For the first day the infant is sick, you should report an initial hospital care code (99221-99223), not normal history and examination (99431), says Shirley Fullerton, CMBS, CPC, CPC-H, academic director for the Medical Association of Billers in Las Vegas and a coder for MedQuist, a national Internet coding and transcription company based in New Jersey. After the first day, report the appropriate subsequent hospital care code (99231-99233), she says.

For example, a baby may be normal at delivery thus warranting 99431 with jaundice developing the second day necessitating a switch to the hospital care codes. If the jaundice decreases by the third day, return to the normal newborn codes, billing 99433.

If you perform any procedure related to a sick neonate's treatment, such as obtaining a blood specimen (36406) or performing a lumbar puncture (62270) or suprapubic bladder aspiration (51010), bill these as well. Procedures are not bundled into the hospital care codes, Tuck says.

To summarize the well-sick-well-again spectrum of codes, if a well newborn develops a problem such as tachypnea shortly after birth but the condition is not critical and the child is subsequently discharged after the condition resolves, the coding scenario would be as follows, Tuck and Fullerton explain:

ICD-9 770.6 for tachypnea

99221-99223 for the initial hospital care, including documentation of all three key components: history, examination and medical decision-making

99231-99233 for each subsequent day of hospital care, including two of three key components

Codes for any procedures performed during treatment, such as collecting a blood specimen (36406)

99238-99239 for discharge day management, depending on the time spent providing discharge services.

Sick Neonate Becomes Critically Ill:Use 99295-99296

Sometimes, a normal newborn will develop a problem, such as respiratory distress, that turns into an acute life-threatening disease, changing the infant's status to critically ill.

To report neonatal critical care codes (99295-99296), you must document organ failure or acute life-threatening disease. You may bill these codes daily, and they include almost all procedures you might perform on a critically ill newborn, such as 24-hour monitoring for a neonate on a ventilator. Critical care is not based on location in the hospital but on a critical condition requiring cardiac and/or respiratory support, Fullerton says.

CPT states that the first time a newborn requires critical care within the first 30 days, and the pediatrician admits it to the neonatal intensive care unit (NICU), you should use 99295 (Initial neonatal critical care, per day, for the evaluation and management of a critically ill neonate or infant, 30 days of age or less). Any critically ill infant admitted or readmitted within the first 30 days of life qualifies for neonatal critical care codes, coding experts say.

For each subsequent day the neonate requires critical care, report 99296 (Subsequent neonatal critical care, per day).

Keep in mind that NICU codes do not include newborn delivery attendance (99436) or newborn resuscitation (99440, Newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output), so you should report these codes separately, if appropriate, Tuck says. (Codes 99436 and 99440 cannot be reported together, as detailed below.)

A neonate who is no longer critically ill may still be in the NICU, but because the infant no longer requires such interventions as a ventilator to help it breathe, it may not qualify for 99295-99296. If this is the case, use the appropriate subsequent hospital care code (99231-99233), Fullerton says.

So, to recap the coding progression when a neonate becomes critically ill, follow this sequence offered by Richard A. Molteni, MD, FAAP, vice president and medical director at Children's Hospital and Regional Medical Center in Seattle:

If the neonate is a normal newborn at birth, report 99431.

If the child later becomes critically ill and is admitted to the NICU the same day, report the additional code 99295 appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). (Check with individual payers about reimbursement for 99295 appended with modifier -25, because some carriers may be reluctant to pay for both normal newborn and critical care delivered on the same day.)

For each subsequent day the neonate is critically ill, report the subsequent critical care code (99296).

When the infant is no longer critically ill, use the subsequent hospital care codes (99231-99233).

Report the appropriate discharge code (99238-99239) on the day of discharge.

Critically Ill at Birth,Then Well Enough to Go Home

When a neonate has a life-threatening condition such as cardiac or severe respiratory distress at birth and is critically ill, report emergency intervention services and neonatal critical care codes.

Specifically, if the pediatrician performs positive pressure ventilation and/or chest compressions, you should report the resuscitation code 99440, Molteni says.

When the same pediatrician attends at delivery and resuscitates a neonate, that pediatrician cannot report both 99436 (Attendance at delivery [when requested by delivering physician] and initial stabilization of newborn) for attendance at delivery and 99440 for the resuscitation, according to CPT.

Remember that you should report resuscitation (99440) separately and in addition to the per-day, global neonatal critical care codes (99295-99296), Molteni says. Again, use 99295 for the initial day of critical care and 99296 for each day the child remains critically ill.

When the infant is no longer critically ill and weighs more than 2,500 grams, you should use subsequent hospital care codes (99231-99233), Molteni says.

If the newborn is no longer critically ill and weighs 1,500 to 2,500 grams, however, report 99299 (Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant [present body weight of 1500-2500 grams]) instead of 99231-99233.

If the noncritically ill infant's present weight is less than 1,500 grams, report 99298 ( very low birth weight infant [present body weight less than 1500 grams]) instead of 99231-99233, Molteni emphasizes.

Many babies who qualify for 99298 "progress" to that code from the critical care neonatal codes. Some will go back and forth between 99298 and 99296 if, for example, they require reintubation or develop necrotizing enterocolitis.

Although many pediatric coders think that 99298's 1,500-gram threshold applies to birth weight, it refers to present weight weight the day the service was provided.

Note: Newborn care coverage varies from payer to payer. You should verify coverage and guidelines with individual payers to prevent denials.