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Coding Questions for the Neonatologist

September 2014

From Dr. Michael Whitman:

In my group practice, the Neonatologists perform the transports of infants to our hospital. Sometimes because of geography, we arrive at the referral hospital in our own car before the ambulance. We attend to the infant at the outside hospital, then follow the rest of the transport team back to the NICU in our own car.
Can we still bill for transport time (face to face) during the transport back to our NICU? It is clear that we can bill for the face to face time at the outside hospital, but the actual transit time is unclear. We are still part of the transport team, just not in the same vehicleJune, 2014

The answer from Ed Liechty:
In my opinion, one cannot charge for face to face time if not in direct physical proximity to the patient - following the ambulance in a car would not qualify.  So I think you would not be able to include the time driving back.  CPT is pretty clear on this, using the term “direct face-to-face care”.  The bigger question is whether you would be considered part of the transport team by a payer if you do not ride in the transport vehicle.  If not, then presumably you could not even bill for the time in the referring hospital.  Also note that the same physician cannot bill both direct face-to-face time and non face-to-face supervision time. The alternative would be to bill 99291-292 for hourly critical care while at the referring hospital - but if you admit to your own service you could not bill both hourly and a global code. 

From Stephen Pearlman:
Face to face means exactly that.  I don’t think that you could bill for that time considering you would not be in the ambulance with the patient.  I also agree that it would be hard for you to bill for the time at the referring hospital.  I think you might be able to bill for procedures but this would probably be a hard sell to the payer as well.

June 2014

From Kate Stanley, M.D

Can Neonatal Nurse Practitioners bill the codes 99466/99467 – face to face pediatric critical care patient transport codes (I am assuming the NNPs are members of the group practice, not the hospital)?

The physician coders at Michigan are struggling with this because the CPT description of the code reports that the physician must deliver the transport care. In contrast, the AAP 2014 Coding for Pediatrics indicates that the transport care must be delivered by a physician or qualified health care provider aka: NNP/PA.

The answer is you can bill, but may not get paid depending on your state-see below…..

From Stephen Pearlman:

The critical care transport codes can be billed by a “qualified health care provider” such as a nurse practitioner. However, she or he must be credentialed by the payer and it must be within the scope of practice within that State. Each State licenses NPs differently so the person asking the question needs to familiarize herself with the licensure and scope of practice in Michigan.

From Ed Leichty:

The short answer in my opinion is that NNPs can bill this code in the sense that it would not be illegal or fraudulent. At Indiana we do bill this code for our NNPs. After some negotiations we have begun getting paid by commercial payers. We have been consistently denied by Medicaid They state they are prohibited by CMS from paying non physicians for these codes. We are currently negotiating with Indiana Medicaid to obtain a waiver from CMS.

May, 2014

From Jose M Arias-Camison, M.D.

What happens when a neonate is admitted from birth and must remain in the same hospital past the 28th day:

1. Continue to report the birth status as primary because they are still admitted from birth (V30.00, V30.01, etc.).
2. Continue to report all appropriate codes from perinatal chapter because the conditions began or originated in the perinatal period (categories 760-779).
3. Continue to report all other conditions that are considered clinically significant.

I got this from an AAP webinar but I do not have any source.

Coders are telling us that diagnosis have to change after 28 days. The ICD-9 CM book says that chapter 15 category codes are from birth to 28 days. It does not say what to do after 28 days.

Stephen A. Pearlman MD, MSHQS answers:

If the condition originated in the perinatal period we should continue to utilize those codes for as long as it clinically applies.

Therefore, as an example using the following scenario:

A neonate born at 28 weeks gestation develops apnea of prematurity on day 3 of life and is started on caffeine. You place the ICD 9 code 770.81 at that time. On day 30(beyond the perinatal period which is up to day 28, remembering that the day of birth is considered day
0) the same baby continues to have apnea. Should you continue to use the ICD code
770.81 once beyond the perinatal period?

The answer is yes because according to ICD 9 and 10 Official Guidelines for Coding and Reporting “Should a condition originate in the perinatal period, and continue throughout the life of the patient, the perinatal code should be continued to be used regardless of the patient’s age”. If on the other hand a condition appears for the first time after the perinatal period, a non-perinatal code should be utilized instead (for example, if NEC occurs on day 30).

April 2014

Cindy Walden, CPC, CCS-P asked:
Who can bill 99465 - - Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output?
The physician documents that he/she arrived 8-10 minutes after delivery and CPAP was being administered; may that physician bill for the resuscitation?  I do not think so, but the E/M university stated:  The attending physician must provide direct patient contact and be readily available. The doctor doesn’t have to do the procedures or provide 24-hour in-house coverage, but he needs to be physically present at some time during that 24-hour period to examine the patient and review the patient’s care and plan with the healthcare team. Does this apply to 99465? Does the person not have to do the procedure?

Stephen A. Pearlman MD, MSHQS
The response to the question is straightforward.  First, in order to code for DR attendance 99464 or 99465 the provider must be physically present.  Sometimes you may arrive a few minutes late but still you must participate in the care.  If there is a mid-level  provider there such as an NNP or resident/fellow they may be providing the hands on care while you oversee them.  But you still must be physically present.  The other aspect of the question is what constitutes resuscitation.  According to  CPT, CPAP does not qualify as positive pressure ventilation.  Therefore if only CPAP is used one must code 99464.  In order to qualify for 99465 one must either give actual breaths and/or chest compressions.

Regarding the issue of 24-hour coverage, if you are using one of the global codes for 24 hour coverage such as 99468 or 99477, the provider needn’t be in house or be the one doing all of the procedures or care. But the provider who is coding for the 24 hour service must see the patient, round with the team, review the interval history and daily data (VS and labs) and supervise the care of the patient.  Furthermore, the attending must thoroughly document that they have seen the patient and their role in the patient’s care.  This rule does not apply to procedures or E/M codes that are not for a full 24-hour period.  In that case such as resuscitation, one must be there for the majority of time that the service is being provided.

Gil Martin MD
If the doc arrives and the baby is still in the DR and provides care, meaning some degree of hands on resuscitation (even a few positive pressure breaths), the doc can "officially" use 99465.  If the baby is not in DR or in the NICU- no.  If the baby wrapped and doing  The only time this can be used when the doc arrives after the delivery is if the physician actively works on the baby at that time.  However, that said, the note must document the active participation, it might be best to use a "consultation" type code (if allowed in your State) and avoid the delivery room code completely.  The E/M University used the right words: Physically present and direct patient contact.  Although the use of 99465 can be used legally, I personally would go the other route unless, the doc actually did some meaningful resuscitation (doesn't have to be complete--but more than a simple look or the use of a stethoscope).

January 2014

From Dr. William Stratton

1000 gram 28 week infant now a month old on low flow cannula and caffeine for stable apnea of prematurity, in an isolette for thermal support, on continuous electronic heart rate and oxygen saturation monitoring and gavage fed. Neonatologist and NNP are part of same practice group. This Non-critical care infant evaluated and a focused physical assessment done by NP before bedside rounds with MD, neonatal dietician, social service and nursing. Infant's bedside nurse presents patient and team discusses current status and plans for the day. Any pertinent physical findings from NP exam are verified by the MD.  Plans for day and any longer range plans discussed with team. All this occurs at bedside during collaborative rounds. NP documents these findings and plan for day in daily progress note in EMR. MD reviews note, makes any corrections, additions, or clarifications and comments, appends the appropriate attestation statement and signs and then bills for the day under his name. The note clearly delineates MD contribution to that days’ assessment and plan and his agreement or disagreement with NP's assessment. Any problem with this shared care in a non-critical patient? Does MD need to do his own focused physical assessment after reviewing and agreeing with NP's findings?

Answer from Gil Martin, MD:
As far as the physician code is concerned, since this is not high flow nasal cannula simulated CPAP this would not qualify for a critical care code.  Therefore 99478 is the intensive care code which is appropriate since there is continuous monitoring of vital signs.  Now, the difficult part is the NNP issue.  If the NNP works for the group and sees the patient along with the physician then as long as there is an attestation by the doc that he did a physical examination and participated in the care then the code can be placed by the doc even if the NNP did most of the work.  If the NNP is employed by the hospital, the doc can paraphrase her note, but must write a separate note in order to qualify for placing the 99478 code.

So therefore the use of the NNP is basically to make life easier for the doc and the information she provides can be part of the final note for the day.  No longer can the doc sign the note and say I agree with nurse xxxxxxxx.  The attestation becomes the critical element.

Answer from Stephen A. Pearlman, MD:
The scenario below should be being billed as a 99478. There is no problem with the shared care model that is being delivered by the team.  The physician documentation must be more than a simple attestation such as “agree with above” but documents that the doctor saw the patient, reviewed the data and  formulated the plan of care.

The clinical vignette that was used for 99478-99480 when they were presented to the CPT editorial panel and the RUC included an independent physical assessment by the billing physician.  This may be a focused exam and some of it may be done by observation (breathing comfortably etc.) but there must be documentation that the doctor has at least laid eyes on the patient if not hands.  Personally, I physically examine them all in a brief focused exam.

December 2013

From Dr. Satyan Lakshminrusimha

I need some input regarding initial care coding from institutions that do not mandate attending physicians to stay in house for night call. For example, a 24-week infant is born at 10 PM on 8/29/13 and is managed by a fellow overnight. The attending physician comes in at 730 AM on 8/30/13, examines the baby and reviews the chart and puts in an admit note. Does the attending physician bill initial critical care (99468) for 8/30 or 8/29 or not at all (and bill only subsequent critical care - 99469 for 8/30)?

Answer from Gil Martin, MD:
The answer to this question is clearly delineated in CPT.  The attending physician can only place a code when the patient is evaluated.  Therefore his code is placed on 8/30/13 would be 99468. The difficulty with this scenario, is that the hospital will have the admitting date for the patient for 8/29/13.  The fellow can write the admitting note for the day and the doc can use portions of that note in his/her own assessment but can only bill for the patient the date that there is his/her participation in the care.

Answer from Stephen A. Pearlman, MD
In the circumstance described the proper coding is for the attending to bill for 99468 on 8/30.  There can never be coding by the attending for work that she or he did not participate in (i.e. must be physically present and document one’s presence).  Furthermore, 99468 is for the initial day of critical care which does not mean that it must be the day of birth.  It is the first day that the attending sees the baby and provides critical care.  In the scenario that would be 8/30 not 8/29.

It is also important to note that the day of birth is considered day 0 regardless of the first day you bill for your services.  This becomes important if the baby remains critical on day 29 of life.  At that point (day 29) the code needs to change from 99469 to 99472.

September 2013

Jody R Gross, MD from Marshfield WI asks:

The neonatology service covers the regular newborn nursery, as well as infants in the NICU. My question is this:  NICU doc #1 does a routine newborn exam on a baby on day of life #1, and charges. Later that evening, the baby becomes critically ill, and is moved to the NICU, under the care on NICU doc #2 Can the NICU doc #2 charge 'Initial Critical care?'  Currently, our hospital does not allow 2 'admission' charges on the same day. 

The expert answer from Stephen A. Pearlman, MD

When a well-baby is born the proper initial code on day 0 is 99460.  If the baby becomes critical the same day it is permissible to code 99468 the same day for that patient whether it is the same provider or not.  However, if the baby starts out moderately ill requiring intensive care and the provider codes 99477 then later the same day the baby becomes critical, one cannot use 99468 in addition to the 99477.  In that case, it is most appropriate to code just the 99468 for the highest level of service provided that day. In yet another similar scenario, if a baby is intensive but not critical on day 0 and one codes using 99477 then the baby becomes critical the next day (day 1) the proper code is 99468.  This is because day 1 is the initial day of critical care, which needn’t be the day of admission.

June 2013

The following question from Dilip Purohit, MD is frequently asked:
What is the right code for a premie on nasal CPAP of 30% O2:  Critical care follow up code vs wt based intensive care code? The question can be extended to NIPPV when used in the management of apnea and bradycardia.

From the Coding Expert, Dr. Gil Martin:
We are teaching that NCPAP constitute a critical care code.  It is also important to have an attestation in the note which states that "there is a high probability of imminent life threatening or deterioration of the patient's condition" if the therapy is withdrawn.

February 2013

Michelle K. Chiu, MD, FAAP asked:
The question I have is on ICD9 codes for babies who are now > 30 days. Many of the codes we have used (beginning with the 7—‘s) has been dedicated to the neonatal period. But we often have babies who are ELBWs, who are now over 30 days, and when we try to code for certain diseases, such as chronic lung disease (770.7) or NEC Stage I (code 777.51), we are told by our hospital coders that we are not allowed to use these codes anymore since the babies are over 30 days, and should use instead other ICD9 descriptors (in our example, CLD 518.82 and NEC Stage I is 557.0). The coders are changing our ICD9 diagnosis and submitting for reimbursement.
Will you all be able to help us determine which code is the right one we should use for the babies in the Neonatal ICU? Are we allowed to continue to use the Neonatal ICD9 codes that were given to us from the section the entire hospital NICU stay for our patients, or do they indeed switch at > 30 days of life?

Linda Waldman asked:

Should we be billing for the 2 month immunizations (90460 /90461) for our preterm infants who are still admitted in the NICU or would it be bundled under the hospital charges?

And, the answers are »

January 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.

The correct code(s) for the work done by the neonatologist is:

  • (A)99468-25, 31500-59, 36660-59, 32551-59
  • (B) 99468-25, 32551
  • (C) 99468-25, 31500, 36660-59, 32551-59

October 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.

The correct code(s) for the work done by the neonatologist is:

  • (A)99468-25, 31500-59, 36660-59, 32551-59
  • (B) 99468-25, 32551
  • (C) 99468-25, 31500, 36660-59, 32551-59

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 2012


A 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 code(s) are:

  • (A) 99479, 94780, 94781
  • (B) 99479
  • (C) 99472, 94780, 94781

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
The car seat/bed testing codes (94780, 94781), if used in the hospital are bundled with the critical care code (99472) and the intensive care code (99479). However, the car seat/bed code can be reported on the same date as the subsequent hospital care codes (99231-99233) and discharge day management codes (99238-99239). This differs if the repeat test is performed in the pediatrician's office where the code is not bundled. (CPT 2012 pages 40-41, 505: Coding for pediatrics, pages 141-142, 146-148).

July 2012


A 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:
A.  99291, 31500, 99466-25
B.  99471, 99466, 31500
C.  99472, 99466

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.

The correct code for Neonatologist B is:
A.  99468
B.  99471
C.  99472

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:

  • A. 99465, 94610, 99468
  • B. 99468, 36660, 36510
  • C. 99468

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:

  • A. 99221
  • B. 99464
  • C.99465

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:

  • A. 99221
  • B. 99464
  • C.99465

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:

  • A. 99465
  • B.99465, 31500-59
  • C.99465-25, 31500, 94610-59

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 2012

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."

November 2011

You 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:

  • A. 99472, 62270-59, 51100-59, 36420-59
  • B. 99469
  • C. 99472

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 October

A 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 2011

Neonatologist 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:

  • A. 99468
  • B. 99291, 99292
  • C. 99466
  • Answer: (B) 99291, 99292

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:

  • A. 99288
  • B. 99468, 99288-25
  • C. 99466
  • Answer: (B) 99468, 99288-25

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 2011

The 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:

  • A. 99464, 99468
  • B. 99464, 99477
  • C. 99465, 99477

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 2011

A 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:

  • A. 99478
  • 99233
  • 99469

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 2010

You 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:

  • A. 99238
  • B. 99239
  • C. 99233

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 2010

You 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:

  • A. 99221
  • B. 99222
  • C. 99477

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 2010

A 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?

  • A. 99403
  • B. 99243
  • C. 99251
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