Pediatric Coding Alert

You've got a handy in-between hospital code that can let your pediatrician capture more than sick care but less than critical care.

Overlooking 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services) can cut approximately $165 from your inpatient bottom line if you mistakenly code 99223 (Initial hospital care ...) instead, but misuse can result in insurer requested paybacks.

See if your 99477 use is on target by spotting the errors in this real newborn care claim submitted as:

Restrict 99477 to Admission Day.

You can't use 99477 multiple times during a hospital stay, says Barbara J. Cobuzzi, MBA, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions in Tinton Falls, N.J. In the code's descriptor, "the word 'admission' means admission to inpatient in the hospital."

Rule: Reserve 99477 for the first day of initial intensive hospital care. Provided the infant meets the code's work requirement, you can apply the code to three scenarios, says Richard Molteni, MD, a neonatologist at Children's Hospital & Regional Medical Center in Seattle and an AMA CPT advisory committee member. Babies (28 days or less) who:

1. the physician admits as sick from the delivery room

2. were normal newborns and then became sick in the hospital

3. were readmitted to the hospital and not critically ill.

Use 99477 When Infant Very Ill, Not Critical

Pigeonhole 99477 with 9.30 relative value units (RVUs) on the 2008 Medicare Physician Fee Schedule and a national payment of approximately $354 (9.30 x 38.0879 conversion factor) as the in-between code. You should use this code for when the baby is not sick enough for critical care but due to the visit's complexity needs more reimbursement than the initial hospital care codes include.

Hint: Think intensive care. Code 99477 holds for any neonate less than 28 days needing intensive monitoring and observation, usually in an intensive care unit (ICU) (but not critically ill), agrees Molteni.

For a baby who requires more or less care than intensive care services, look to 99295 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less) (24.59 RVUs, $937) on the high side or 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) (2.45-4.96 RVUs, $93-$189) on the low end. Use 99295 if the neonate meets CPT's critical care definition: failure of one or more organ systems that causes a high probability of imminent or life threatening deterioration in the patient's condition.

For a baby who does not require critical or intensive care but is not normal (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]) (1.54 RVUs) as shown with an ICD-9 code other than the a newborn V code, such as V30.00 (Single liveborn; born in hospital; delivered without mention of cesarean delivery), the pediatrician should report the appropriate level of initial hospital care (99221-99223).

Look at Severity for Subsequent Day Codes

After 99477, the newborn could remain in intensive care, improve but remain sick, or become well. Based on the required care, Molteni says to code using the following guidelines.

Putting It Together

For the initial newborn care claim presented above, once the neonate requires intensive care, you would choose the appropriate subsequent intensive care code based on the infant's weight.

Example: A term infant has a normal delivery and normal hospital course until day three. At that time the infant develops vomiting and temperature instability with mild respiratory distress requiring treatment, oxygen, sepsis workup and the initiation of IV antibiotics. The infant is admitted to the intensive care unit for required frequent monitoring, reevaluation and communication with the family, but the infant remains stable with treatment.

If the infant has a present body weight on days three and four of 2501-5000 grams, you would report the claim as:

 Lesson learned: When a neonate requires intensive care on subsequent days, look to 99298-99300.