Pediatric Coding Alert

High-risk deliveries can mean a lot of waiting around for pediatricians. The physician is almost always summoned to the delivery, they may do an extensive amount of work once the baby is born, or they may do nothing more than stabilization.

Thomas J. Catalanotto, MD, administrator of Pediatric Associates of Fairfield in Fairfield, OH, is a subscriber who has submitted to PCA three vexing reimbursement challenges from his practice. Catalanotto specializes in high-risk coverage at a level 2 neonatal center. The response comments are provided by Richard H. Tuck, MD, FAAP, an AAP coding trainer and a practicing pediatrician in Zanesville, OH.

Scenario #1: I am called to attend delivery because of thick particulate meconium. I am requested to arrive at 9:30 pm, which I do. The infant is finally delivered at 11:30 pm. There is particulate meconium. The infant is intubated two times and thick particulate meconium is suctioned from the trachea. The patient is subsequently perfectly fine, requires no oxygen or IV fluids, is placed in the special care nursery for observation, and goes out to mom within an hour.

I usually code this situation in the following way: 99436 -- Attendance at delivery when requested by the delivering physician, and stabilization of the newborn; CPT 31520 -- Laryngoscopy/intubation and suctioning of the newborn; 99431 -- Care of the normal newborn.

Comment: Tuck agrees with using 99436 and 99431. However, he does not think 31520 is the appropriate code for dealing with intubation and aspirated meconium. What he did was intubate the infant, he says. I suggest using 31500. The descriptor for 31500 is Intubation, endotracheal, emergency procedure. The descriptor for 31520 is Laryngoscopy direct, with or without tracheoscopy; diagnostic, newborn.

(Tip: Remember, when CPT has indented codes, you should go to the top code and insert the indented descriptor after the semi-colon in the descriptor on the top, unindented code.)

In this situation the pediatrician is not doing a diagnostic procedure; he was intubating. The code immediately preceding 31520 -- which is 31515 -- might be appropriate also under slightly different circumstances. The descriptor for 31515 is Laryngoscopy direct, with or without tracheoscopy; for aspiration. If the infant had not required intubation, 31515 should have been used, says Tuck. If he just looked and aspirated, he should use 31515.

(Note: So when would Tuck use 31520? We dont, he says. Its more for pediatric ENTs, when they have to do a diagnostic laryngoscopy on a newborn.)

Scenario #2: I am called by the OB to attend the delivery of a premature 30-week infant. I arrive at 7 am. Delivery takes place at 8 am. The infant is a 29 weeker, approximately 2 pounds. The baby requires resuscitation at delivery with apgars of 1, 4, and 8. The infant is brought into the special care nursery and requires intubation and ventilation because of inadequate respiratory effort. Our local Childrens Hospital is called to transport the infant to the Newborn Intensive Care Unit in Cincinnati. The infant requires IV fluids, plasmanate for stabilization of poor profusion, and insertion of an umbilical arterial line for blood gas management.

I would code this case as follows: 99436 -- Attendance at delivery; 31520 -- Intubation of the infant; 99291 -- critical care codes -- used until the infant is transported to Childrens.

Comment: Tuck agrees with the use of 99436 for attending the delivery. However, 31520 is not the code for intubation. Instead, 31500 (intubation, endotracheal, emergency procedure) should be used. Tuck agrees with the use of the critical care codes, but notes that the umbilical arterial line should get its own code. The umbilical line is not included in critical care. The code for the umbilical line is 36660 (catheterization, umbilical artery, newborn, for diagnosis or therapy).

Scenario #3: I am called to attend the delivery of an infant of a diabetic mother. I have three hours of standby time waiting for the infant to deliver. I am not doing any other activities except waiting for this infant to deliver. The old code for standby can no longer be used, and I am not sure how I will be reimbursed for the three hours of standby. Subsequently the infant delivers and is a 35 week LGA, IDM. The baby requires ventilation in the delivery room and resuscitation for inadequate respiratory effort. I ended up spending two hours in direct care of this patient for stabilization. The tracheal tube does not remain, however. The infant is placed in 60-percent oxygen and weans over the next few days.

In my office this is coded as follows: 99436 -- Attendance at delivery; 99255 -- Consultation, because I was called by the OB.

Comment: This time, Tuck suggests an alternative to the use of 99436. "This infant required ventilation and resuscitation in the delivery room," he says. Instead of 99436 (which doesn't includes newborn resuscitation), Tuck recommends using 99440 (newborn resuscitation) only. The relative value for 99440 is higher than for 99436. The reimbursement would be higher, therefore. Subsequent to that, the critical care codes should be used, instead of the consultation code, which Tuck calls "unusual." The consultation code is "an option for getting reimbursed, depending on the insurance company," Tuck concedes. "But it's not the optimal way to code for an infant. You are only indirectly indicating the services you provided." So use the critical care codes (99291, 99292) instead, he urges. Also, Tuck notes that Catalanotto cheated himself out of a hospital admissions code. "In this case, the physician keeps the baby, the infant doesn't transfer," he says. "So an admit code should be used." Tuck recommends 99223, the highest level code for initial hospital care. As for the three hours of standby time, some experts would recommend the use of 99360 in 30-minute increments for the use of standby time. Others would recommend 99436, regardless of the time involved.