Pediatric Coding Alert

When a newborn is critically ill and is in the NICU there are specific CPT codes for the care of this baby. The codes are 99295 for the first day, 99296 for subsequent days for the critically ill and unstable neonate or infant, and 99297 for subsequent days for the critically ill though stable neonate or infant. These codes have many typical procedures included in them.

Liz Munn, CPC, practice plan manager for the department of pediatrics at Medical University of South Carolina Medical Center in Charleston notes that there are no documentation requirements for the NICU codes. With the wording of the NICU care codes it is difficult to determine at which point in the NICU care a patient is a 99296 [unstable] or a 99297 [stable], she writes. Can you provide any additional resources or information?

Code Definitions

99295 is for the date of admission. The neonate or infant must be critically ill, and must require cardiac and/or respiratory support (including ventilator or nasal CPAP), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. This code includes preoperative evaluation and stabilization in cases of life-threatening surgical or cardiac conditions.

99296 and 99297 are for subsequent days, and have the same requirements as 99295. The key is whether the baby is stable or unstable. For 99296, however, the neonate or infant must be unstable, and most will require frequent ventilator changes, intravenous fluid alterations, and/or early initiation of parenteral nutrition. 99296 will commonly be used for neonates who have just had operations or who become critically ill and unstable during their hospital stay. 99297 would be used when there were less frequent changes in respiratory, cardiovascular, and fluid and electrolyte therapy.

Stable or Unstable?

The dilemma, of course, is how to define stable and unstable. As Munn relates, different neonatologists and pediatric intensivists have different views of what these two terms mean. We have 10 neonatologists, and when you get them all together, you get 9 different opinions, says Munn. She is concerned that in general, the problem is undercoding. We have scenarios that come up every day, relates the plan manager. For example, in my opinion, a patient is a 99296 if the baby is having a septic workup and has apnea episodes, she says. But not all doctors would agree. And some neonatologists will say that a 1,000-gram baby who is off the ventilator is stable, while some say that any baby under 1,000 grams is unstable, adds Munn. Their 33-bed unit is a busy one, with eight coders -- how can she make sure everyone is coding the same way?

If we try to define inside the CPT book what pinpoints them as stable or unstable, were going to have a problem, says Richard A. Molteni, MD, FAAP, who is on the CPT Editorial Panel, Chair of the AAPs perinatal section, and a member of the AAPs RBRVS PAC. What wed have is every state Medicaid agency and Blue Cross representative out there with a pencil and a checklist, he says. If the baby were unstable but didnt have a central catheter, theyd reject the claim. Molteni cites New York Medicaid, which uses the criterion of six blood gases being monitored as a definition of unstable. This just creates an artificial way to upcode, he notes. Babies who have hyaline membrane disease but are getting better, with the vent settings down, may require more blood gases to be tested, he says. That doesnt make them unstable.

However, Molteni notes that physicians use the words stable and unstable all the time. When you write your daily note, in one way or another, you know if the baby is stable. You write, `This is day 8, this is a 1,000-gram infant, and you then say whether the baby is stable or unstable. As the neonatologist describes the child, it should be clear to other physicians whether stable or unstable applies. It should be written so that most caregivers can understand it, adds Molteni.

Physician Communication Key

Should Munn and other coders be worried about inconsistencies among their group over these codes? Yes, says Molteni. But he acknowledges that it is a very common problem. The solution is for the neonatologists to talk to one another, he recommends.

The problem is not a definition of stable and unstable, the physician explains. The problem is that the neonatologists havent sat around as a group and decided to agree on what their group definition of stable and unstable is. One way such a consensus can be arrived at is for the physicians in the group practice to step back and ask if an independent auditor (one who knows newborn medicine) would agree with the majority of the neonatologists on what constitutes stable vs. unstable, suggests the physician.

That said, Molteni, who joined the CPT editorial panel after the NICU codes were put in, is not happy with the stable and unstable wording. And in fact, a fourth code will be added in the future for continuing care for a child whose body weight is less than 1500 grams. This code would be appropriate for the feeders and growers.

NICU Bundled Services

The care included under the three NICU codes (99295-97) is what differentiates it from the utilization of critical care codes. Here are the procedures which are bundled into the NICU codes:

enteral and parenteral nutritional maintenance
metabolic and hematologic maintenance
pharmacologic control of the circulatory system
parent counseling
case management
direct supervision of the health care team
umbilical or peripheral vessel catheterization
oral or nasogastric tube placement
endotracheal intubation
lumbar puncture
suprapubic bladder aspiration
bladder catheterization
initiation and management of mechanical ventilation or continuous positive airway pressure
surfactant administration
intravascular fluid administration
transfusion of blood components
vascular punctures
invasive or non-invasive electronic monitoring of vital signs
bedside pulmonary function testing
monitoring or interpretation of blood gases or oxygen saturation

If NICU codes are used, any services provided which are not on the above list may be billed separately.

Not included in the NICU codes are attendance at delivery (99436) and newborn resuscitation (99440). Also not included: placement of a central venous or percutaneous catheter (36488), cutdown (36490), thoracentesis for aspiration (32000), and thoracentesis with tube insertion (32002).

Consult Codes for Pediatricians

The physicians who use the three NICU codes are mainly neonatologists, says A.D. Jacobson, MD, of Pediatric Associates, Phoenix, AZ. Most insurance carriers wont reimburse two people, says Jacobson.

So usually, the neonatologist is the one using these codes. However, the parents frequently want their pediatrician to be involved. The neonatologist usually takes over the care, says Jacobson, but the pediatrician wants to be familiar with the patient, too.

How can the pediatrician get involved when the NICU codes are used? Jacobson offers this tip: have the neonatologist request a consultation with the pediatrician. This will let you help the family, too.

The consult codes are 99251-99255.

Critical Care Codes

The problem isnt confined to the NICU; whether to use critical care codes is not clear, says Munn, even if a child is in the PICU. The pediatric intensivists who work in the pediatric intensive care unit disagree too, she notes. Some will say if a child is not on a vent, its not intensive care.

But as is often the case with coding, there is nothing that says you have to use the NICU codes. You do have a choice, says Jacobson. The NICU codes, however, are to be billed by the day. Critical care codes are to be billed in 30-minute increments, after the first hour. So in newborn situations, the critical care codes are usually used prior to transport.

The critical care codes are to be used when the infant requires constant physician attendance. This does not mean that the pediatrician needs to be at the bedside, but must be engaged in physician work directly related to the individual patients care. Critical care codes are reported in 30-minute increments (99292 for the first 30 minutes and 99291 for the first hour).

The following services are included in the critical care codes:

interpretation of cardiac output measurements
chest x-rays
blood gases, and information data stored in computers (e.g. ECGs, blood pressures, hematologic data)
gastric intubation
temporary transcutaneous procedure
ventilator management
vascular access procedures

Its helpful to remember that NICU codes are generally used when a patient is getting that service for a whole day. If its only for part of the day, critical care codes are used.