Pediatric Coding Alert

Question: If we bill 99468 for neonatal intensive care, can we also bill a prolonged service code if a pediatrician spends an extensive amount of time at the neonatal intensive care unit (NICU) in face-to-face conferences with specialists and with the patient’s parents?

Illinois Subscriber

Answer: The guidelines accompanying 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) note that “the pediatric and neonatal critical care codes include those procedures listed for the critical care codes (99291, +99292).” That includes “time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit.”

The guidelines go on to elaborate that “discussing the critically ill patient’s care with other medical staff and “time spent on the floor or unit with family members or surrogate decision makers … may be reported as critical care, provided that the conversation bears directly on the management of the patient.” So, all of the services you say your pediatrician provided count toward 99468.

Per their descriptors, the prolonged service codes +99356 (Prolonged service in the inpatient or observation setting, requiring unit/floor time beyond the usual service; first hour …) and +99357 (… each additional 30 minutes …) can only be used to document time “beyond the usual service.”

As all of the services your pediatrician performed are a part of the usual 99468 evaluation and management (E/M) service, and as the code covers all critical care services provided during a 24-hour period, you cannot report prolonged services in addition to critical care services in this particular case. Additionally, prolonged care can only be used with a code that has time associated with it, and since the NICU codes do not have time associated with them (in other words, they are 24-hour codes), they cannot be billed together. 

And remember this: Code 99468 “may only be reported once per hospital admission” and “only once per calendar day” per CPT^® guidelines. Likewise, it can only be reported by one provider, not multiple providers, even if they saw the patient on the same date of admission. If your pediatrician performs critical care for the patient for more than the initial day, you should report 99469 (Subsequent inpatient neonatal critical care, per day …) for each additional day.