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 [...]