Advanced Search

Primary Care Coding Alert

Pediatric Coding Corner:

You No Longer Have to Struggle With 2 Neonatal Definitions

Published on Wed Oct 27, 2004

CPT 2005 conforms to ICD-9, WHO's 28-day period


If you're tired of trying to remember whether a neonate becomes an infant when she turns 28 days or 31 days, you can finally commit the 28th day to memory.

Because ICD-9 and CPT defined the neonatal period differently, family physician (FP) coders had to make sure they matched the right definition with the right coding system. CPT 2005, however, ends the age debate.

Neonate Describes Infant Under 29 Days of Age

FPs have wondered about applying the term "neonate." CPT 2004 defines a neonate as 30 days or younger, says David G. Jamiovich, MD, pediatric transport program medical director at Hope Children's Hospital in Oak Lawn, Ill. "But, ICD-9 and the World Health Organization (WHO) end the neonatal period after the 28th day of life."

CPT 2005 makes its definition consistent with ICD-9 and the WHO. "I'm glad to hear that," says Victoria S. Jackson, owner and executive director of OMNI Management Inc., a medical practice management and billing company in Lake Forest, Calif. The change will make coding less confusing, she says.

The change, however, shouldn't impact coders significantly. "It's always nice to have definitions from different sources correlate," says Jaime Darling, CPC, certified coder for Graybill Medical Group, which has nine family physicians, in Escondido, Calif. But more important, coders should continue to pay close attention to the infant/child's age to select an appropriate code.

CPT Cuts 2 Days from Neonatal Critical Care

For coding, this means CPT shifts the neonatal codes down a few days. When the CPT 2005 codes become effective Jan.1, the revised neonatal critical care codes will read:

  • 99295 - Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less

  • 99296 - Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less.

    These codes previously referred to a neonate as the first 30 days of life. The pediatric period then started at 31 days of life.

    Codes 99293-99294 Start at 29 Days

    The pediatric codes 99293-99294 also contain revisions to reflect the neonatal definitions' age shift. Pediatric critical care codes will include infants 29 days of age and older. The proposed codes appear in the 2005 CPT manual as follows:

  • 99293 - Initial inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age
  • 99294 - Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age.

    Old way: In 2004, you would have used the codes for patient older than 30 days of age.

    You Lose 2 Days of Higher-Paying 99295

    The neonatal and pediatric critical care revisions come with some good and bad reimbursement news.

    The good news: The revisions are only editorial. So the codes' relative value units (RVU) won't change.

    Count your losses: The neonatal code revisions cut two days from your neonatal critical care pay. In 2004, when you admit a critically ill infant who's 29 or 30 days old, you would charge the higher-paying neonatal initial critical care code (99295) (24.69 RVUs or $921.92 [2004 National Physician Fee Schedule rates]).

    Starting Jan. 1, for the same encounter, you'll charge the lower-valued pediatric initial critical care (99293) (21.78 RVUs or $813.27).

    Subsequent critical care charges remain almost the same. Codes 99296 (neonatal) and 99294 (pediatric) contain 10.82 and 10.76 RVUs respectively.

    • Other Articles in this issue of

    Primary Care Coding Alert

    View All