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ED Coding and Reimbursement Alert

What's the Definition of a Neonate?

Published on Fri Nov 26, 2004

 CPT lines up neonatal codes with  ICD-9, WHO's time frame

If you've struggled with knowing when to report a neonate code versus an infant code, CPT 2005 provides the final piece of the puzzle. Because of various neonate definitions, physicians must often assign the term differently - but next year's CPT book nixes the discrepancy and makes the definitions consistent.

Count the First 28 Days of Life as Neonatal Period

CPT 2004 defines a neonate as 30 days or less, says David G. Jamiovich, MD, a 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."

Problem solved: CPT 2005 makes its definition consistent with ICD-9 and the WHO. That's good news for coders. When you're talking about the same patient, it doesn't make sense to apply one definition to code the diagnosis and another to code the critical care services, says Patricia S. Wildman, RHIA, CCS-P, clinical reimbursement auditor at Children's Hospital Boston.  

Because CPT brings its definition more in line with ICD-9's perinatal/newborn definition, the change will make assigning codes for these patients less confusing.

Include 2 Fewer Days for Codes 99295-99296 

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.

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

    Start Pediatric Critical Care Codes at 29 Days

     The pediatric codes also contain revisions to reflect the 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.

    Previous method: In 2004, you would have used the codes for a patient older than 30 days of age.

    Early Shift Sacrifices More Than $100

    The 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.

    The bad part: 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) (24.99 RVUs or $946.68, 2005 National Physician Fee Schedule rates).

    Starting Jan. 1, for the same encounter, you'll charge the lower-valued pediatric initial critical care (99293) (21.82 RVUs or $826.92).

    Subsequent critical care charges remain almost the same. For 2005, codes 99296 (neonatal) and 99294 (pediatric) are valued at 10.85and 10.84 RVUs.

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