Pediatric Coding Alert

Coders for pediatric and neonatal practices frequently wonder what the age parameters are for the neonatal intensive care codes (99295-99298). CPT states that these codes are for critically ill newborns and very low birth weight infants. Exactly what is the age limit for these codes, which pay very well? Neonates are defined as being less than 28 days old, writes Becky Smathers, professional fee analyst of Childrens Hospital of Michigan at Wayne State University in Detroit. Can these codes be utilized only for neonates admitted to the NICU? she asks.

If the infant is 30 days old or younger, you can use codes 99295-99298, says Richard A. Molteni, MD, FAAP, a member of the AMAs CPT Codes editorial panel and RBRVS PAC and past chair of the American Academy of Pediatrics (AAP) perinatal section. And you can continue using these codes until the child is discharged to go home, as long as he or she is critically illeven if the baby stays in the hospital well over 30 days. However, once a baby weighs 1500 grams or more, and is not critically ill, you must switch to using the subsequent hospital care codes (99231-99233).

Molteni, who is the AAP expert on these codes, is using 30 days, not 28, because that is the number of days the AMA considers a month. The 30-day limit will be included in the forthcoming version of the AAPs Coding for Pediatrics, says Molteni, who writes the chapters on neonatal intensive care codes.

First Month of Life

If an infant is admitted to a critical care unit in the first month of life, you should be using the neonatal intensive care codes, says Molteni, who is also vice president and medical director of Childrens Hospital and Regional Medical Center in Seattle, WA. What if the baby goes home on the fifth day of life, but comes back on the sixth? You should still use the neonatal intensive care codes, he explains, noting that the readmission would be a 99295 (initial neonatal intensive care) and not a 99296, 99297, or 99298 (which are all for subsequent neonatal intensive care). As long as the readmission occurs during the first month of life, you should use 99295 for each, says Molteni. With hospital admissions, you get more than one code per lifetime, depending on how many times the patient is admitted. The same is true for initial neonatal intensive care codes, even if there are only 30 days during which they can be used at all.

Note: If the baby goes home, and is readmitted when older than 30 days, you should use the critical care codes (99291, 99292), says Molteni.

The neonatal intensive care codes you would most commonly use (after 99295 for the initial day) during the first month are 99296 (subsequent neonatal intensive care, per day, for the evaluation and management of a critically ill and unstable neonate or infant) and 99297 (subsequent neonatal intensive care, per day, for the evaluation and management of critically ill though stable neonate or infant). For feeders and growers who are no longer critically ill but still under 1500 grams, you would use the new code, 99298 (subsequent neonatal intensive care, per day, for the evaluation and management of the recovering very low birth weight infant [less than 1500 grams]).

Note: The 1500 grams in 99298 refers to present weight: This code can be used for any non-critically ill neonate until they reach 1500 grams body weight, regardless of age. For the critically ill use 99296 or 99297. For the non-critically ill, over 1500 grams present body weight, use the subsequent hospital care codes (99231-99233).

The neonatal intensive care codes include many procedures which are bundled, such as umbilical lines, lumbar punctures, surfactant administration, CPAP or ventilator initiation and management, intubation, oral or nasogastric tube placement, and more. The critical care codes also have bundled procedures, but not the same ones; for example, bedside pulmonary function testing, which is bundled into the neonatal intensive care codes, is separately billable when using the critical care codes. So in shifting from the neonatal intensive care codes to the hourly critical care codes, you will have to make sure you start billing for any procedures which had been bundled into the neonatal intensive care codes.

The critical care codes (99291-99292) are time-based99291 is for the first hour of critical care, and should be used only once per date, and 99292 is for each additional 30 minutes beyond the first hour.

Child Who Stays Past 30 Days

What about the baby who is admitted to a critical care unit during the first month of lifeand thus is billed using the neonatal intensive care codesbut who stays in that unit for three months? The child is no longer a neonate. But the neonatal intensive care codes should still be used, providing that the child didnt go home. As long as the baby is in the hospital after being admitted continually, you should use the neonatal intensive care codes, says Molteni. (Remember, there is a new neonatal intensive care code99298for the recovering low-birth-weight infant who is no longer critically ill. So you can still use the neonatal intensive care codes even if the baby is no longer in a critical care unit, providing the baby has not gone home within the first month of life.) For example, for a very premature baby who has been in a NICU for three months, you would still be using neonatal intensive care codes even though the baby is well over a month old.

Coding for Transfers and Location

There is a difference between a baby who has gone home and a baby who is being transferred, notes Rosalyn Adler, practice manager for Neonatology Associates of Atlanta, GA. If a child has been transferred from another hospital, its OK to still use the neonatal intensive care codes, even if the baby is older than a month, says Adler.

Also, Adler reminds us that the neonatal intensive care codes do not have to be used in a NICU. They may not call it a NICU in your hospital, says Adler. But if a ventilator is being used, its probably at least a CCU.

And Molteni takes this a step farther. These codes are not limited to NICUs, and theyre not even limited to neonatologists, he says. A general pediatrician can use them as well. In some parts of the country, such as Wyoming and Montana, neonatologists are few and far between. There are NICUs and PICUs, however, but general pediatricians provide the care. Of course, in other parts of the country, there are plenty of neonatologists, and insurance plans refuse to pay anyone but a neonatologist to use these codes. That, as Molteni remarks dryly, has nothing to do with coding.