Pediatric Coding Alert

Question: When caring for a high-risk newborn who is transferred to another facility, is it better to code the procedures separately or to use the neonatal intensive- care codes?

Ohio Subscriber
 
Answer: The intent of CPT is to include procedures on critically ill infants in neonatal intensive-care codes, 99295-99298. For infants who are transferred and critically ill, however, there is the option to code with either the individual procedures or 99295 (initial neonatal intensive care, per day, for the evaluation and management of a critically ill neonate or infant). To determine which is best, you need to add the relative value units (RVUs) for the procedures and see if the total is greater than the neonatal intensive-care code you would use.
 
As an example, a pediatrician was called to a vaginal delivery of a baby who has thick particulate meconium on arrival. The obstetrician suctioned the baby, but the baby was pale and limp. The pediatrician visualizes the cord by laryngoscopy (31500, intubation, endotracheal, emergency procedure) and sees no meconium below the cord. The baby's color improves with positive pressure ventilation, but there remains some respiratory distress. The pediatrician initiates CPAP (94660, continuous positive airway pressure ventilation [CPAP], initiation and management) and orders blood tests.
 
The pediatrician then places a UAC (36660, catheterization, umbilical artery, newborn, for diagnosis or therapy) or a UVC (36510, catheterization of umbilical vein for diagnosis or therapy, newborn) and, later, discusses the case with a neonatologist at a children's hospital for transfer. Finally, the pediatrician starts IV antibiotics and prepares the baby for air evacuation. The time spent with the newborn is four hours in intensive care, with a final diagnosis of meconium aspiration syndrome.
 
If the pediatrician were to code the procedures individually, he or she would report 99223 (initial hospital care, per day; 4.20 RVUs), 99436 (attendance at delivery [when requested by delivering physician] and initial stabilization; 2.42 RVUs), 31500 (3.29 RVUs), either 36660 (1.96 RVUs) or 36510 (1.70 RVUs), 94660 (1.48 RVUs), 99356 (prolonged physician service in the inpatient setting requiring direct [face-to-face] patient contact beyond the usual service [e.g., maternal fetal monitoring for high risk delivery or other physiologic monitoring, prolonged care of an acutely ill inpatient]; first hour) (2.45 RVUs), and 99357 ( each additional 30 minutes) x 4 (2.47 x 4 RVUs). The RVU total is 25.68 if an arterial line (36660) is used, or 25.42 if a venous line (36510) is used.
 
The alternative is to code 99295 (21.72 RVUs) and 99436 (2.42 RVUs), for a total of 24.14 RVUs.
 
Therefore, in the above example, coding the procedures would pay better than the neonatal intensive-care code. In addition to coding based on which set of codes yields the highest number of RVUs, one other consideration may lead the transferring pediatrician to choose the procedure codes instead of 99295. Theoretically, both the transferring and receiving physicians should be able to bill 99295. Often, however, the insurance company will pay only one provider for this code. The transferring pediatrician, however, could bill the procedure codes, and the receiving neonatologist could bill 99295.
 
This illustrates the controversy that erupted when the critical-care code (99291-99292) verbiage was changed to require physicians to use the neonatal intensive-care codes for the first 30 days of life. Some pediatricians objected to the change and would have preferred to use the critical- care codes, which are not per-day but rather based on actual time spent.
 
The situation would be different if the baby were remaining in the same facility. You could not switch from neonatal intensive-care codes to procedures and back every time one code choice paid better than the other. For example, if you are billing 99297 (subsequent neonatal intensive care, per day, for the evaluation and management of a critically ill though stable neonate ) for a baby who is stable, and the baby has a bad day and becomes unstable, requiring several procedures, you must revert to 99296 (subsequent neonatal intensive care, per day, for the evaluation and management of a critically ill and unstable neonate ) rather than to the procedure codes.