Pediatric Coding Alert

Yes, you can sometimes look past newborn critical care codes.

Coding for newborn care in the hospital is usually fairly straightforward, whether the baby is considered a normal newborn or one who needs special care. Confusion can arise, however, if the baby takes a turn for the worse and needs to be transferred to a tertiary care center. When you find yourself in that situation, keep three important points in mind to help guide your choices.

Scenario: A newborn is initially considered normal, but develops respiratory distress syndrome (RDS, 769). The infant develops respiratory failure on the second day and requires nasal CPAP, progressing to a  ventilator. The infant’s condition deteriorates and your physician makes arrangements to transfer the infant to a children’s hospital with a neonatal tertiary intensive care unit on the third day. The baby is stabilized and transported.

Keep Critical Care Codes to Full Day

Everything is fine when the pediatrician sees the infant on the first day, so you code the visit with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant). Because the infant’s status changes to critical on day two, report that day’s services with 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger).

Caution: Don’t code the next day of critical care, however, with 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) as you might expect. The infant transfers to the tertiary care center that day. The receiving physician at the tertiary care center will submit 99468 for the transfer day (his initial day of neonatal critical care). You would use the hourly critical care codes 99291 (Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes) and +99292 (… each additional 30 minutes [List separately in addition to code for primary service]).

“The insurance company, understandably, would not pay for a full day of neonatal critical care for physicians at both hospitals,” says Richard L. Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. “In essence, that would represent duplicate payment for the infant’s care.”

Learn When to Use ‘Older’ Codes Instead

“You might think you need to always use the neonatal critical care codes for newborns and that hourly critical care codes are for older children,” Tuck says. “But that’s not always the case.”

Correct option: In this transfer scenario, the transferring physician should code for the critical care delivered and for stabilizing the infant for transport. “Remember that the critical care codes include many procedures the pediatrician would provide such as 36600 (Arterial puncture, withdrawal of blood for diagnosis) and 94002 (Ventilation assist and management, initiation of pressure or volume present ventilators for assisted or controlled breathing; hospital inpatient/observation, initial day),” Tuck says.

“Time spent providing procedures not included in 99291 and +99292 should be subtracted from the critical care time billed,” Tuck adds. This includes procedures such as 36660 (Catheterization, umbilical artery, newborn, for diagnosis or therapy).

Check for Transport Assistance

If the transferring physician accompanies the newborn on the transport to the tertiary care center, you’ll add one or two more codes to your claim.

Depending on how long the transport takes, submit 99466 (Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured patient, 24 months of age or younger; first 30-74 minutes of hands-on care during transport). Then add +99467 (… each additional 30 minutes [List separately in addition to code for primary service]) as appropriate.