Utilizing NICU and Critical Care Codes Correctly for Optimal Reimbursement
Published on Wed Apr 01, 1998
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. [...]
