Wiki Neonatal Critical Care/Prolonged Services

[clbarry8033]

I am a certified E/M coder, but do not have much experience with Pediatric hospital billing. Could you help me with a couple of these questions?

1. Are you allowed to bill the Initial neonatal critical care code (99468) and the prolonged service code (99356) for the same day?

2. And am I right in thinking that if a critical baby is transported to another hospital on the same day of admission, that our physicians should bill the critical care codes (99291-99292) instead of the initial neonatal critical care code (99468)?

3. If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?

I would love some solid resources that I could take to my providers if possible.

Thank you very much!

 

[Sherrina]

I work directly with the NICU providers in our organization, here is my understanding of NICU coding:

1. Are you allowed to bill the Initial neonatal critical care code (99468) and the prolonged service code (99356) for the same day?
Neonatal critical care codes are reported "once per day, per patient, per hospital stay" of ongoing critical care services provided (see CPT guidelines under "Inpatient Neonatal and Pediatric Critical Care"). Prolonged care codes are used when services are "beyond the usual physician or other qualified health care professional service time" (See CPT guidelines under "Prolonged Services"). There is a chart to show the proper coding for total duration of prolonged services and how to calculate (ie: 30-74 min beyond typical service time - 99354 x1). Due to the 24 hour coverage timeframe for the NICU codes, there would not be services beyond the "usual" time. Therefore, only the neonatal critical care code would be billed, it would not be appropriate to add prolonged care.

2. And am I right in thinking that if a critical baby is transported to another hospital on the same day of admission, that our physicians should bill the critical care codes (99291-99292) instead of the initial neonatal critical care code (99468)
Since the neonatal critical care codes can only be billed 1 x per day per patient, our NICU provider will utilize the time based critical care codes (99291-99292) when preparing a baby for transport to another facility.

3. If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?
If our physicians are billing 99291-99292, they must document the amount of time spent on critical care services since these are time based codes.

Most of my information comes directly form the section guidelines in the CPT book, however, another good resource is the Section on Neonatal-Perinatal Medicine from the American Academy of Pediatrics.

Hopefully this helps, I would be interested in hearing if anyone handles these scenarios differently.

 

[mcanas@mams1.com]

I work directly with the NICU providers in our organization, here is my understanding of NICU coding:

1. Are you allowed to bill the Initial neonatal critical care code (99468) and the prolonged service code (99356) for the same day?
Neonatal critical care codes are reported "once per day, per patient, per hospital stay" of ongoing critical care services provided (see CPT guidelines under "Inpatient Neonatal and Pediatric Critical Care"). Prolonged care codes are used when services are "beyond the usual physician or other qualified health care professional service time" (See CPT guidelines under "Prolonged Services"). There is a chart to show the proper coding for total duration of prolonged services and how to calculate (ie: 30-74 min beyond typical service time - 99354 x1). Due to the 24 hour coverage timeframe for the NICU codes, there would not be services beyond the "usual" time. Therefore, only the neonatal critical care code would be billed, it would not be appropriate to add prolonged care.

2. And am I right in thinking that if a critical baby is transported to another hospital on the same day of admission, that our physicians should bill the critical care codes (99291-99292) instead of the initial neonatal critical care code (99468)
Since the neonatal critical care codes can only be billed 1 x per day per patient, our NICU provider will utilize the time based critical care codes (99291-99292) when preparing a baby for transport to another facility.

3. If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?
If our physicians are billing 99291-99292, they must document the amount of time spent on critical care services since these are time based codes.

Most of my information comes directly form the section guidelines in the CPT book, however, another good resource is the Section on Neonatal-Perinatal Medicine from the American Academy of Pediatrics.

Hopefully this helps, I would be interested in hearing if anyone handles these scenarios differently.

Ok what happen if the doctors has conference with other specialist and have face to face conference with h the parents and the baby is in Neonatal critical care this service is beyond the usual physician service time?

 

[RupeshS]

If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?
If our physicians are billing 99291-99292, they must document the amount of time spent on critical care services, need clarity on 99291-99292 if time is not documented, which codes will be using.

 

[hblawless]

Statement out of CPT " If the same individual provides critical care services for a neonate or pediatric patient in both outpatient and inpatient settings on the same day, report only the appropriate neonatal or pediatric critical care code 99468-99472 for all critical care services provided on that day. Also report 99291-99292 for neonatal or pediatric critical care at one facility but transferring the patient to another facility,"
These two sentences are in direct contrast to one another and completely confuse all coding staff. In just these two sentences it reflects to bill 99468-99472 and 99291-99292 on the same day at the originating facility. This is not correct since it is a 9948-99472 are day codes, and 99291-99292 are time based. This is very difficult to interpret.
The facility receiving this patient uses the day code 99468-99472. So this leaves the originating facility to only bill the 99291-99292. Difficult thing for physicians to understand is how to document this. EMR's have multiple templates that they think they can use. Others they do not know what to use. We need AMA CPT clarification on this issue. Mean time Use 99291-99292 to bill and hope to receive the time on the document what ever form they use.

 

[Tami_F]

Ok what happen if the doctors has conference with other specialist and have face to face conference with h the parents and the baby is in Neonatal critical care this service is beyond the usual physician service time?

There is no "usual physician service time" when it comes to the attending provider that is billing a pediatric or neonatal critical care. All care provided to the patient on a particular DOS is included in the appropriate age-based critical care code.

If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?
If our physicians are billing 99291-99292, they must document the amount of time spent on critical care services, need clarity on 99291-99292 if time is not documented, which codes will be using.

Physicians need to document correctly. If they are documenting critical care for a pediatric or neonatal patient as the attending physician, you should bill using the appropriate age-based code. If they are not the attending provider and documenting critical care without specifying the time, you should query the provider for more information so that you can correctly bill 99291 and/or 99292 as appropriate.

Statement out of CPT " If the same individual provides critical care services for a neonate or pediatric patient in both outpatient and inpatient settings on the same day, report only the appropriate neonatal or pediatric critical care code 99468-99472 for all critical care services provided on that day. Also report 99291-99292 for neonatal or pediatric critical care at one facility but transferring the patient to another facility,"
These two sentences are in direct contrast to one another and completely confuse all coding staff. In just these two sentences it reflects to bill 99468-99472 and 99291-99292 on the same day at the originating facility. This is not correct since it is a 9948-99472 are day codes, and 99291-99292 are time based. This is very difficult to interpret.
The facility receiving this patient uses the day code 99468-99472. So this leaves the originating facility to only bill the 99291-99292. Difficult thing for physicians to understand is how to document this. EMR's have multiple templates that they think they can use. Others they do not know what to use. We need AMA CPT clarification on this issue. Mean time Use 99291-99292 to bill and hope to receive the time on the document what ever form they use.

These statements are not in contrast to each other.

Pediatric critical care codes are "global" codes, which means that all the critical care services the attending physician/physician group provides to the patient over the course of a 24 hour period are included in the age-based critical care code. If the provider you are billing for provides critical care services to a patient in both an outpatient and inpatient setting on the same DOS, all of that critical care would be accounted for by billing the appropriate age-based critical care code. If the provider you are billing for is not the attending, you should use the time-based critical care codes, 99291-2 for the total amount of critical care provided, regardless of place of service.
If the patient is admitted to your facility and care is transferred to another facility on the same DOS, your providers should be documenting the amount of time they spent providing critical care to the patient on the date of transfer. In that instance, your providers (at the transferring facility) will bill time-based critical care, 99291-2, and the providers at the accepting facility should bill the appropriate age-based code.

 

[agrove008]

I work directly with the NICU providers in our organization, here is my understanding of NICU coding:

1. Are you allowed to bill the Initial neonatal critical care code (99468) and the prolonged service code (99356) for the same day?
Neonatal critical care codes are reported "once per day, per patient, per hospital stay" of ongoing critical care services provided (see CPT guidelines under "Inpatient Neonatal and Pediatric Critical Care"). Prolonged care codes are used when services are "beyond the usual physician or other qualified health care professional service time" (See CPT guidelines under "Prolonged Services"). There is a chart to show the proper coding for total duration of prolonged services and how to calculate (ie: 30-74 min beyond typical service time - 99354 x1). Due to the 24 hour coverage timeframe for the NICU codes, there would not be services beyond the "usual" time. Therefore, only the neonatal critical care code would be billed, it would not be appropriate to add prolonged care.

2. And am I right in thinking that if a critical baby is transported to another hospital on the same day of admission, that our physicians should bill the critical care codes (99291-99292) instead of the initial neonatal critical care code (99468)
Since the neonatal critical care codes can only be billed 1 x per day per patient, our NICU provider will utilize the time based critical care codes (99291-99292) when preparing a baby for transport to another facility.

3. If the total time for critical care is not documented, how would I bill the admission and the discharge (transfer)?
If our physicians are billing 99291-99292, they must document the amount of time spent on critical care services since these are time based codes.

Most of my information comes directly form the section guidelines in the CPT book, however, another good resource is the Section on Neonatal-Perinatal Medicine from the American Academy of Pediatrics.

Hopefully this helps, I would be interested in hearing if anyone handles these scenarios differently.

Hi Sherrina, I was wondering if the above information still holds true? I'm struggling to find ANY information regarding if you can bill prolonged care on the same day as neonate critical care. Our Pediatric Hospitalists are billing Initial critical care 99468 and prolonged 99356 along with 99464. What's even more confusing is that under CCI edits checker, it states you can bill them together and there is no edit. Please help!