Pediatric Coding Alert

CPT 2006 expands subsequent care codes to include normal-weight newborn

Knowing the new 2006 method for reporting subsequent intensive care of a noncritically ill normal-weight infant should pay you $100 more than the 2005 method.

In addition to adding several editorial notes to critical care services, CPT 2006 revamps the intensive care subcategory and adds one new code. To ensure correct coding of these services when the changes become effective Jan. 1, educate yourself and your coding staff on these fundamentals.

1. Transition From 99300 to 99231-99233

You should add a new code to the coding continuum of care for sick babies. "Code 99300 finishes the continuum of managed care for patients who require enhanced observation and monitoring," says Richard A. Molteni, MD, FAAP, the American Academy of Pediatrics representative to the AMA CPT advisory committee. When a noncritical newborn weighs more than 2,500 grams, you can now continue to use intensive care codes.

Old method: "In 2005, you would have reported subsequent intensive care of a non VLBW/LBW newborn with subsequent hospital care codes," says Molteni, who is also a neonatologist and medical director at Children's Hospital and Regional Medical Center in Seattle. When a noncritical infant who had been previously critically ill had a present body weight of 2,501 grams or more, you had to switch from 99299 (Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant [present body weight of 1500-2500 grams]) to 99231-CPT 99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...). Intensive (non-critical) low birth-weight service codes ended when the infant exceeded 2500 g.

New way: To capture care of a newborn weighing 2,501-5,000 grams, CPT 2006 creates continuing intensive care code 99300, which describes "Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501-5000 grams)."

"The new intensive care code doesn't require the newborn to be very low or low birth weight (VLBW/LBW)," says Patricia S. Wildman, RHIA, CCS-P, clinical reimbursement auditor in the compliance department at Children's Hospital Boston.

On claims for 2006, when an infant who requires intensive care weighs more than 5,000 g (about 11 pounds), you'll switch from 99300 to 99231-99233. The new coding continuum is contained in the chart included with this article:

Heads up: Failing to incorporate the new code could cut almost $100 from a claim. For instance: If you report subsequent intensive care (SIC) of a recovering 3,500-g infant with 99233 instead of 99300, you'll receive $54.54 instead of $149.16, based on the 2006 National Physician Fee Schedule. The fee schedule, which uses a conversion factor of 36.1171, assigns:

• 2.09 relative value units to 99233
• 5.64 RVUs to 99300.

2. Consider This Care Indicative of SIC

CPT adds clarifying language to help define SIC. The revised subcategory's introductory notes now reflect, "continuing intensive care of the low birth weight (LBW, 1500-2500 grams present body weight) infant, very low birth weight (VLBW, less than 1500 grams present body weight) infant, or normal weight (2501-5000 grams present body weight) newborn who does not meet the definition of critically ill but continues to require:

• intensive observation
• frequent interventions
• other intensive services."

Still not sure how to recognize SIC? CPT Changes 2006: An Insider's View, published by the AMA, offers these examples of such care:

• continuous cardiac and/or respiratory monitoring
• continuous and/or frequent vital signs
• temperature maintenance
• enteral and/or parenteral nutritional adjustments
• laboratory and oxygen monitoring.

These guidelines indicate that SIC codes no longer require the patient to have been previously critically ill. "In 2005, if an infant was never critically ill, you couldn't use 99298-99299 even if the patient met the weight criteria," says Deborah F. Rushing, CPC, a coding specialist at Management Consultants for Affiliated Physicians (MCAP), which serves neonatalogists in Virginia. The revised language allows physicians to capture care for normal-weight infants who meet the AMA's SIC definition, regardless of prior critically ill status.

Be careful: "Don't assume you can code SIC services based solely on an infant's weight," Rushing says.
Example: A 2,501-gram infant who needed a sepsis work-up is now in an open-air crib while the neonatologist awaits lab results. The patient does not require intensive observation, frequent interventions and other intensive services. "You wouldn't bill intensive care for this patient," she says. Because the infant does not meet the SIC definition, you would instead assign subsequent hospital care with 99231-99233.

3. Learn 3 Billing Basics of 99298-99300

The revised SIC instructions answer some other commonly asked coding questions that address these concerns.

1. Attendance: The neonatologist doesn't have to be in constant attendance to report 99298-99300. Instead, he must provide direct supervision of the healthcare team that provides constant observation of the recovering infant.

Translation: The attending physician must provide direct patient contact and be readily available, Wildman says. "The doctor doesn't have to do the procedures or provide 24-hour in-house coverage." But he needs to be physically present at some time during that 24-hour period to examine the patient and review the patient's care with the healthcare team, she says, referring to CPT Assistant August 2000's guidelines for direct physician supervision neonatal intensive care.

2. Care day: You should assign 99298-99300 on subsequent care day(s). "On day one, use the appropriate E/M code that represents the care the physician provided for the patient," Rushing says.

"If the patient was admitted as critically ill and then improved, you could use 99295," Molteni says. For an infant who does not fit the critically ill requirement, assign 99221-99223 (Initial hospital care ...).

3. Global identity: The SIC codes are per-day codes. So you should report 99298-99300 "only once per day, per patient," CPT says.

"Codes 99298-99300 capture multiple small rounds of care as opposed to the single encounters that hospital visit codes typically represent," Molteni says. A physician who provides intensive care may perform four or five care circles each day that include talking to the patient's parents, revisiting the infant, checking labs and x-rays, and reviewing the care plan.

4. Lump 36400-36406 With Critical/SI Care

Pediatric and neonatal critical care service codes (99293-99296) now include vascular access procedures (36400, 36405, 36406). When using 99293-99296, you should no longer separately report:

• 36400--Venipuncture, under age 3 years, necessitating physician's skill, not to be used for routine
venipuncture; femoral or jugular vein

• 36405--...scalp vein
 • 36406--...other vein.

These inclusions also apply to continuing intensive care services. Codes 99298-99300 "are global codes with the same services bundled as outlined under codes 99293-99296," CPT states.

Pediatric critical care patient transport codes already include vascular access procedures. "The new inclusions keep the critical care service-procedure bundles uniform," says Jeffrey F. Linzer Sr., MD, FAAP, FACEP, associate medical director for compliance and business affairs at EPG--Children's Healthcare of Atlanta at Egleston. The across-the-board edits mean you don't have to keep track of different bundles for these categories/subcategories:

• pediatric and neonatal critical care services
• pediatric critical care patient transport
• continuing intensive care services.

The global codes still bundle intravascular fluid administration. CPT 2006 updates the inclusion to reference the new hydration service codes (90760-90761) in place of the deleted codes (90780-90781).