Pediatric Coding Alert

When pediatricians provide services for newborns going in and out of the neonatal intensive care unit (NICU), proper coding depends as much on documenting who performs a service as it does on documenting what service is performed.

Consider the following scenarios to avoid incorrectly reporting the pediatrician's services and double-billing for the neonatologist's services.

Sometimes the baby is born without problems, later becomes ill, goes to the NICU and returns to the regular nursery. The pediatrician handles all of the patient's care and codes accordingly.

For example, suppose an obstetrician delivers a baby who is admitted to the nursery by the pediatrician. On day one, the pediatrician finds that the baby is normal. On day two, the infant develops tachypnea. The pediatrician is called, and he examines the infant.

For the admittance to the nursery on day one, the pediatrician assigns the normal newborn examination code 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 examination on day two, the day of the illness, he bills the appropriate level of subsequent hospital care (99231-99233), linked to the diagnosis code for tachypnea (770.6 ).

Do not report subsequent hospital care for the normal newborn (99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day) for this visit, because the baby is now abnormal, says Richard Molteni, MD, FAAP, a neonatologist and medical director of Children's Hospital and Regional Medical Center in Seattle. In addition, you should not bill an initial hospital care code (99221-99223) because the pediatrician already examined the newborn in the hospital. Therefore, the service constitutes subsequent care, not initial care.

When the pediatrician discharges the infant, report a hospital discharge (99238, Hospital discharge day management; 30 minutes or less; 99239, more than 30 minutes).

However, if the baby's condition is more severe, requiring critical care in the NICU, the neonatologist may assume care. In this case, the neonatologist rather than the pediatrician reports the services in the NICU.

For example, suppose the baby goes to the normal nursery after birth, but on day two develops signs of sepsis, is critically ill, and is transferred to the NICU where the neonatology unit takes over the care.

If on day two the pediatrician assesses the baby for illness, he can charge for his services as a 99233 (highest level of subsequent hospital care) with procedures prior to transfer to the neonatologist (99295, Neonatal intensive care). The insurance company could question this, so it might need to be appealed with documentation.

Although the pediatrician still reports 99431 for day one, the neonatology unit bills for the initial neonatal intensive care with 99295 (Initial neonatal intensive care, per day, for the evaluation and management of a critically ill neonate or infant), Molteni says. The unit links the diagnosis code for sepsis (038.xx, Septicemia) to the intensive care code.

If the pediatrician visits the baby while in the NICU under the care of the neonatologist, billing would be very difficult, says A.D. Jacobson, MD, FAAP, chairman of the American Academy of Pediatrics section on administration and practice management. The neonatal intensive care codes are per-day codes, meaning the neonatologist bills for an entire day of care. An insurance company would probably deny payment for a pediatrician visit as well, unless the neonatologist requested a consultation.

If the baby is in a hospital without an NICU and the community pediatrician can deliver the critical care the baby needs, the pediatrician bills an intensive care code (99295-99298). However, the baby must be critically ill, at least with organ system failure, to qualify for these codes.

If the baby is transferred to another hospital because the community pediatrician and birth hospital cannot provide the needed care, the pediatrician codes a hospital discharge and procedures.

An alternative would be for the pediatrician to code a subsequent hospital day, prolonged services and procedures. This would then capture the extended time that might be required to care for such a critically ill infant. The discharge code would not allow for billing for the extended time because the code is an open-ended code for more than 30 minutes.

If the pediatrician must accompany the infant to another hospital, you may report patient transport codes 99289 (Physician constant attention of the critically ill or injured patient during an interfacility transport; first 30-74 minutes) and +99290 (... each additional 30 minutes [list separately in additional to code for primary service]), which require constant physician attention.

Sometimes the baby has some problems at birth, goes to the NICU, and then is transferred to the regular nursery where the pediatrician first sees the patient. The pediatrician reports his services when care is turned over to him.

For example, a baby is born with tachypnea and goes directly to the hospital NICU without the pediatrician examining the child. On day two, the neonatologist relinquishes care to the pediatrician, and the baby is transferred from the NICU to the regular nursery.

The pediatrician, who is seeing the baby for the first time, bills the normal newborn examination code (99431), not the hospital care codes, Molteni says.

If the baby is discharged to home from the NICU, but the regular pediatrician performs the discharge, bill 99238-99239.

Consultation codes play an important role in newborn billing when the patient is transferred from the NICU to the normal nursery, particularly when the neonatologist wants to involve the pediatrician before moving a patient into a normal nursery.

For example, a 10-day-old infant has been in the NICU since birth due to prematurity and associated problems, but is now stable and ready to move to the normal nursery. The neonatologist consults the pediatrician, who reviews the records and examines the baby. The pediatrician bills an initial inpatient consultation (99251-99255) for this visit, Jacobson explains. Link the consultation code with prematurity (765.x).

Remember that the pediatrician must meet and document the criteria for a consultation including request for the services, rendering of the services, and report back to the requesting physician.

A baby sometimes returns to its birth hospital after staying at another hospital's NICU. For example, a baby is born in a hospital without an NICU, has severe respiratory distress syndrome (769), and is transferred to a facility with an NICU. When stable, the baby is transferred to the original hospital, closer to the parents' home. When the pediatrician receives the patient, report an initial hospital care code (99221-99223). Even though the pediatrician billed an admission code when the baby was first born, a second admission should be coded, Jacobson says.