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 Coding Questions for the NeonatologistJanuary 2013
Dr. Shiv Kapoor from Mercy Medical Center wrote in to the Coding Corner: What is the cutoff for Nasal cannula flow to justify the 99469 code? We are using flow of 2 liter or above, as HFNC for subsequent critical care code. Can we use code 99469/99472, if baby is on NC at 1liter or 1.5 liter? The answer from our Neonatal Coding Experts December 2012
A term infant is born after a normal pregnancy, labor and delivery. The infant has significant respiratory distress and requires NICU admission, intubation and mechanical ventilation (in the NICU). The neonatologist also places an umbilical arterial line. The chest X-Ray reveals a pneumothorax and the neonatologist places a chest tube.
October 2012A term infant is born after a normal pregnancy, labor and delivery. The infant has significant respiratory distress and requires NICU admission, intubation and mechanical ventilation (in the NICU). The neonatologist also places an umbilical arterial line. The chest X-Ray reveals a pneumothorax and the neonatologist places a chest tube.
The correct answer is (B). Code 99468 represents initial inpatient neonatal critical care 28 days or younger. Codes 31500 (endotracheal intubation) and 36660 (umbilical artery catherization) are bundled with the 99468 code. 32551 is the code for a chest tube (not bundled). A -59 modifier is used with a procedure if more an one "non-E/M" procedure is done. The -25 modifier is used to alert the payer that there was a significant separately identifiable E/M by the same physician on the same day from another service. (CPT 2012, page 40; Coding for Pediatrics 2012, page 149). August 2012A 2300 gram former 26 week gestational age infant, now 40 days of age is preparing for discharge. A car seat test is ordered as part of the discharge process. The baby is stil on continuous cardiorespiratory monitoring. The car seat test procedure takes 90 minutes and includes continuous nursing observation, continuous recording of pulse oximetry, heart rate and respiratory rate. The neonatologist interprets the results of the testing and recommends that the baby be discharged in a car bed fo repeat testing at the pediatrician's office in one month.
The correct answer is (B). Code 99479 is the code for subsequent intensive care, per day, for the evluation and management of the recovering low birth weight infant (present body weight of 1500-2500 grams). Code 94780 is the code for car seat/bed testing for airway integrity, neonate, with continual nursing observation and continuous recording of pulse oximetry, heart rate and respiratory rate, with interpretation and report; 60 minutes. Cod 94781 is the code for each additional full 30 minutes. Code 99472 is the code for subsequent inpatient pediatric criticare, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age July 2012A 30 day old former 28 week gestation baby is transferred to your Level 3 center from a Level II hospital that is not covered by your group. The 1.6 kg baby had been feeding, in room air but suddenly developed abdominal distension and bloody stool. Neonatologist A at the other hospital intubates the baby (utilizes 10 minutes), started resuscitation and then personally transports the baby to you. The time spent at Hospital A is 70 minutes. The transport takes one hour. You (neonatologist B) admit the baby to your unit and request a stat surgical consult. The correct code(s) for Neonatologist A is: Answer: (A) 99291, 31500, 99466-25 Teaching point: 99291 represents 74 minutes of time. However 10 minutes needs to be subtracted from the 70 minutes for we are using the 31500 intubation code. 99466 is the face-to-face transport code for the first 30-74 minutes. Modifier 25 is placed on the second service that Neonatologist A performs. Answer: (B) 99471 Teaching point: 99471 represents initial pediatric critical care for a patient older than 29 days. This baby is a 30 day old. April 2012
A 25 week 700 gram baby is delivered at your hospital. The baby requires intubation in the delivery room and receives surfactant as per your hospital's protocol. The delivery is attended by a nurse practitioner who works for the hospital. The neonatologist admits the baby and assists in the placement of umbilical arterial and venous catheters. The correct code(s) for the neonatologist for this first day of life is:
Answer: (C) 99468 Teaching point: Since the nurse practitioner works for the hospital, the neotatologist cannot place a code for the delivery and intubation. The umbilical arterial and venous catheters (36660, 36510) are bundled into the global daily codes. March 2012
You attend the delivery of a high risk pre-term birth. The infant has mild respiratory distress. He responds to resuscitation per NRP including CPAP. The correct codes are:
Answer: B, 99464 Teaching point: Although this baby is resuscitated utlizing CPAP, this does not represent true positive pressure resuscitation and therefore the 99464 code is chosen.
The same infant does not respond to CPAP along and requires mask PPV. The correct codes are:
Answer: C, 99465 Teaching point: This baby is now receiving positive pressure ventilation and meets the criteria for 99465.
After failing to respond to bag-mask PPV, you intubate the same infant and decide that surfactant is needed for effective resuscitation, which you then give as part of your treatment. The correct codes are:
Answer: C, 99465-25, 31500, 94610-59 Teaching point: Since the surfactant (96410) is part of the resuscitative process, it can be reported. If surfactant is given by protocol or not part of effective resuscitation, it is not coded. The 59 modifier is only used for the additional procedures after the first one. Modifier 25 is used to indicate a significant separately identifiable E/M. A recent question to the Coding Committee was: "I have an issue with Pneumogram interpretation code used by medical assistant insurance. We were usinig 95806, but they do not accept this one anymore. Please advise."< Dr. Martin's answer: "The pneumogram evaluation is not bundled under neonatal intensive care of critical care serivces. Therefore, it can be billed. Medicaid may pay for this depending upon their local guidelines. The suggested RVU is 5.36 and the Medicaid payment for 2011 is $182.11. There needs to be a form on the chart with the official evaluation of the pneumogram and the plan. If your payor has stopped paying for this, you need to sit down and explain the above. If this is still unsuccessful, send me the information and I will be happy to detail a letter to the appropriate people." AAP Perinatal Coding Expert, Gil Martin, provides a coding question of the month. January 2012A recent question to the Coding Committee was: "I have an issue with Pneumogram interpretation code used by medical assistant insurance. We were usinig 95806, but they do not accept this one anymore. Please advise."< Dr. Martin's answer: "The pneumogram evaluation is not bundled under neonatal intensive care of critical care serivces. Therefore, it can be billed. Medicaid may pay for this depending upon their local guidelines. The suggested RVU is 5.36 and the Medicaid payment for 2011 is $182.11. There needs to be a form on the chart with the official evaluation of the pneumogram and the plan. If your payor has stopped paying for this, you need to sit down and explain the above. If this is still unsuccessful, send me the information and I will be happy to detail a letter to the appropriate people." November 2011You are caring for a former 25-week gestation infant who is now 45 days old. He remains ventilator dependent. Today, he has increased ventilatory requirements and his perfusion is poor. You suspect acquired sepsis. You perform a bladder aspiration and lumbar puncture in addition to obtaining a blood culture. You start approrpiate antibiotics. The correct codes are:
Answer: C, 99472 Teaching point: 99472 is a subsequent inpatient global critical care code for a patient who is older than 29 days, but younger than 24 months. The bladder aspiration and lumbar puncture are bundled into this code. Coding Question from OctoberA recent question to the Coding Committee was: There remains a lot of confusion regarding coding when a baby is on 1)"high flow" (with differing definitions of high flow) nasal cannula with varying concentrations of oxygen, or 2) CPAP with varying concentrations of oxygen. Can Dr Martin give an example when to use "Critical" or "Weight based NICU " codes in these babies? Dr. Gil Martin’s response: High flow nasal cannula has been defined by the coders committee as 1.5 liter flow or more. It is true that some places in the United States use 1 liter flow and others 2 liters flow in order to define high flow nasal cannula. The concentration of oxygen is of little importance. It is important in the note to state the following: "high flow nasal cannula is being used to simulate CPAP". As I mentioned, the definition of critical illness or injury has been clarified so that there is impairment of one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Therefore it is the recommendation of the coding committee of the Perinatal Section that the above statement be placed in the note. For example, I would use the following verbage: Baby A is being placed on 1.5 liter flow/minute at 40% oxygen in order to simulate CPAP. It is my opinion that if this therapy is removed, there is a high probability of imminent or life-threatening deterioration. July 2011Neonatologist A is asked to consult and assume care for a baby with meconium aspiration syndrome who continues to deteriorate. She spends 90 minutes providing critical care services and stabilizing the baby. She requests transfer to the regional NICU, where Neonatologist B assumes care for the baby. Neonatologist A and Neonatologist B are in different groups. Neonatologist B organizes the transport and remains in communication with the transport team and admits this critical baby on the same day. The correct code(s) for Neonatologist A:
Teaching Point: Since the neonatologists are in different groups, the neonatologist at the outlying hospital can utilize the hourly critical care code. This would also allow the referring neonatologist to report many procedures separately, such as intubation, umbilical and arterial lines, etc., since these are not bundled with the 99291 and 99292 codes. The correct code(s) for Neonatologist B:
Teaching Point: The neonatologist at the regional center directs the transport (99288) and admits this critical baby (99468). Modifier 25 is used to indicate a significant separately identifiable E/M. Under the Medicare Physician Fee Schedule, code 99288 is a "B" status code with no RVUs. April 2011The obstetrician asks you to attend a delivery of 34-35 week gestation being delivered by stat C/S for fetal distress. The Apgar Score is 6/8 only requiring blow-by oxygen. The birth weight is 2350 grams. Feeds are attempted and a blood glucose is done before infant is sent to the regular nursery. She is feeding poorly and the blood glucose is 25mg%. A repeat is done and there is no change. Infant is admitted to the NICU where she is started on an IV with D10W and her blood sugar is being monitored. She continues to be a poor feeder and has to be gavaged. The correct codes are:
Answer: B 99464 - Represents attendance at delivery (when requested by the delivering physician) and initial stabilization of newborn. (CPT 2010, page 35; CPT Changes: An Insider's View 2009; Coding for Pediatrics 2010, pages 129-130.) 99477 - Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services. (CPT 2010, pages 37-38; CPT Assistant, Mar 09:3; CPT Changes: An Insiders View 2008; Coding for Pediatrics 2010, pages 128, 145-146.) The attendance at delivery code 99464 is chosen for there is no positive pressure ventilation offered and the baby only needs blow by oxygen. In the description above, this baby is not critical and therefore the critical care code 99468 is not correct.) February 2011A baby boy is born at 28 weeks weighing 1550 grams. He initially has respiratory distress requiring mechanical ventilation and surfactant replacement. By day 3, he weighs 1420 grams, continues to have respiratory distress plus apnea requiring stimulation. He is on high flow (HF) nasal cannula at 2 liters with 30% oxygen. The correct code for day 3 is:
Answer: C 99469 - Represents subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate 28 days of age or younger. (CPT 2010, page 37; CPT Changes: An Insider's View 2009; Coding for Pediatrics 2010, pages 137-141, 145.) The 99478 code is the continuing intensive care code for an infant under 1500 grams. The infant as described continues to have organ failure and satisfies the criteria to utilize the subsequent inpatient neonatal critical care code (99469). December 2010You are discharging a female infant whose mother received insulin during pregnancy for diabetes. The infant required intravenous dextrose for two days. The mother has a close friend who also diabetes, and her friend's first child died of sudden infant death syndrome (SIDS). The parents of your infant insist on home apnea monitoring, and you discuss the pros and cons of this intervention with them. You then spend an additional 45 minutes dealing with a home health agency and an insurance company representative. The correct code is:
Answer: B 99239 - Hospital discharge day management; more than 30 minutes reported by attending physician providing discharge services on a date other than the day of admission. The reporting is based on the total time (time does not have to be continuous) spent performing all final discharge records. These codes may be used to report discharge services provided to patients who die during their hospital stay. (CPT 2010, page 16, CPT Assistant, Sep 06:8, Coding for Pediatrics 2010, pages 109-110.) Although an additional 45 minutes is spent dealing with the home agency representative and the insurance company representative, the prolonged service codes (99358-99359) codes are not used since you cannot add the prolonged service codes to the discharge day codes. Codes 99358-99359 cannot be reported if there is another service with no time limit assigned. The discharge code 99239 is more than 30 minutes with no time limt. Coding for Pediatrics 2010, page 71. September 2010You are admitting a 3.1 kg male to the normal nursery and note that clinical chorioamnionitis was diagnosed during labor. You perform a comprehensive examination and medical decision making is of moderate complexity. You discuss the mother’s history with the obstetrician and order blood cultures and antibiotics. The baby is not on intensive monitoring after admission. The correct code is:
Answer: B 99222- Represents the first hospital inpatient encounter with the patient by the admitting physician. It is an initial hospital care, per day, for the evaluation and management of a patient. The requirements include documentation of a comprehensive history, a comprehensive examination, and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually the problem(s) requiring admission are of moderate severity. Physicians typically spend 50 minutes at the bedside or patient’s hospital floor or unit. (CPT 2010, page 14-15; CPT Assistant Sep 07:12; Coding for Pediatrics 2010, pages 41, 99-100). Since this baby is not on intensive care monitoring after admission, the intensive care admission code (99477) is not used. The 99222 code suggest a 50 minute physician involvement. It is important to remember that documentation of each component, (history, physical examination and medical decision making) must reach the highest level of the E/M service code. If that level is not reached then the lower E/M code is used. April 2010A family meets with a neonatologist to discuss their plans for a future pregnancy and the history of cystic fibrosis in both the maternal and paternal families. The neonatologist spends 45 minutes counseling the family. What is the code for this office visit?
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