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Pulmonology Coding Alert

Get Paid for Visits to the NICU

Published on Fri Mar 01, 2002

Premature infants who require extended stays in neo-natal intensive care units (NICUs) are usually seen by neonatalogists for their critical care needs. In some cases, when a premature infant is in severe respiratory distress, a pediatric pulmonologist is called in. "On occasion they are consulted," says Terrence Zach, MD, neonatologist, Creighton University, Omaha, Neb. "When we consult with a pulmonologist, it is usually for a baby who has a very unusual lung disorder or complication, not for the more common 'preemie lung disease.' "

Background on Neonatal Intensive Care Codes

The physician who provides the overall care and management of the infant or neonate in the NICU uses the neonatal intensive care codes (99295-99298). These codes are not based on the type of provider (e.g., pediatrician, neurologist, pulmonologist). It is possible that a pulmo-nologist could assume the complete and total care of the infant in the NICU. For example, if the pulmonologist is covering for another physician, he or she would use

99295-99298:
  
  •  99295 Initial neonatal intensive care, per day, for the evaluation and management of a critically ill   neonate or infant
     
  •  99296 Subsequent neonatal intensive care, per day, for the evaluation and management of a critically ill and unstable neonate or infant
     
  •  99297 ... of a critically ill though stable neonate or infant
     
  •  99298   ... for the evaluation and management, of  the recovering very low birth weight infant (less than 1500 grams).
     
     
    If the infant is 30 days old or younger, the neonatal codes apply. These codes can be used until the child is discharged, or as long as the infant is critically ill. Once the infant reaches a weight of 1,500 grams or more and is not critically ill, subsequent hospital care codes (99231-99233) are appropriate.
     
    Codes 99295-99298 differ from critical care codes (99291-99292) which are time-based. For example, 99291 is for the 30-74 minutes of critical care and is used once per day. Code 99292 is for each additional 30 minutes. These codes cannot be used for an infant in the NICU.
     
    In addition, neonatal intensive care codes are bundled with many procedures, but critical care codes are not. Such procedures may include ventilator initiation and manage-ment (94656-94657), intubation (31500) and oral or nasogastric tube placement  (91105).

    • Coding in the NICU

    A neonatologist calls in a pediatric pulmonologist to determine if the infant is suffering from subglottic stenosis (478.74). Since the pulmonologist is not assuming the overall care of the infant, NICU codes would not apply. Instead, use an initial inpatient consult code (99251-99255), a code for the diagnostic and treatment procedures, diagnosis, and subsequent hospital care codes if appropriate.
     
    The following is an NICU scenario: The infant has been in the NICU on a ventilator for a month and has failed several times to wean off of it. The pulmonologist performs a bronchoscopy (31624-31656) to examine the airway and attempts to make a definitive diagnosis of 478.74, which is the suspected condition.
     
    Note: While the pulmonologist determines a suspected condition of 478.74, do not use specific ICD-9 codes until the diagnosis is confirmed. Code for symptoms until a definitive diagnosis has been reached.  In this case, the infant or neonate is presenting with dyspnea (difficulty breathing), so 786.09 is appropriate.
     
    Once the pulmonologist performs the bronchoscopy and has definitively diagnosed the infant with subglottic stenosis that requires a tracheotomy, report 478.74 and 31615 (Tracheobronchoscopy through established trachoestomy incision). An emergency tracheostomy code (31603) would not be used because the patient is on a ventilator.

    How Consult and E/M Codes Break Down

    Due to the complexity of this case, the pulmonologist attends to the infant for a long time. Any subsequent visits to treat the infant's condition would be billed as 99231-99233. The higher-level code is appropriate for each visit. Follow-up consultation codes for subsequent visits and care (99261-99263) are not appropriate. "These codes are only used when the physician returns because he or she was not able to render his opinion based on information received in the first visit," says Carol Pohlig, BSN, RN, CPC, department of medicine, Hospital of the University of Pennsylvania, Philadelphia. "They also apply if a physician signs off on a case and is consulted later in the stay for a different problem."
     
    If the pulmonologist continues to care for the infant after discharge from the hospital, use established outpatient codes (99211-99215). These codes apply even if the pulmonologist only saw the infant once in the NICU. "If a physician or a physician within the same practice group has seen a patient for a specific service within three years, then that patient is established," says Jennifer Wilcox, billing office lead, Children's Hospital, Omaha, Neb. A physician may, however, provide a consultation for an established patient, if requested to do so by another physician who is providing that patient's primary care.
     
    To bill consultations for new or established patients (99241-99245 for outpatient, 99251-99255 for inpatient) you must meet certain requirements:

     1. The consultation must be at the request of another physician (i.e., outside the pulmonology practice).

     2.  The consulting physician cannot assume primary care of the patient prior to the consultation.

     3.  Diagnostic or therapeutic services may be initiated, and opinion must be rendered and communicated back to the requesting physician.

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