Pediatricians are accustomed to being summoned to the delivery room by the obstetrician. Sometimes the mother is going to have a c-section. Or sometimes the baby may be in distress, as evidenced by a deceleration in heart rate or meconium with rupture of membranes. The ob may wish to protect him- or herself by having a pediatrician there, or the case may evolve to require the pediatrician's services.
Routine C-sections
Pediatricians summoned to attend a "routine" c-section, in which the baby has no problem, can report 99436 (attendance at delivery [when requested by delivering physician] and initial stabilization of newborn) says A.D. Jacobson, MD, FAAP, an American Academy of Pediatrics coding trainer with Pediatric Associates in Phoenix. In this case, the pediatrician performs the functions normally performed by the nurse, but -- because the pediatrician's attendance was requested -- he or she can bill for attendance.
Choose Code by Child's Status
You may bill either a normal newborn or a hospital admission code with 99436.
For example, the baby is born by c-section and is fine. Report 99431 (history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. [This code should also be used for birthing room deliveries.]) as well as 99436. CPT specifically states that you can bill 99436 and 99431 together -- and this is the only way you will be compensated for the time and resources spent on this case.
Sometimes, the pediatrician is summoned to attend a c-section and the baby develops distress. The distress may be mild, however. For example, the baby develops mild respiratory problems -- for instance, transient tachypnea requiring oxygen, grunting respirations and a respiratory rate of 60. The infant requires oxygen intermittently through the next 16 hours. Intubation and resuscitation are not necessary.
Do not code 99431; instead, report 99436 and a hospital admission -- probably a level two (CPT 99222 , initial hospital care, per day). "This baby does need special care. It's not a normal newborn," Jacobson says.
Billing for Resuscitation
If the newborn requires resuscitation, do not report 99436, even if you were requested to attend the delivery. Instead, code 99440 (newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output). You cannot bill both 99440 and 99436 under CPT rules.
For example, at the c-section, the baby's fetal heart tones drop. The infant has primary apnea and requires positive pressure ventilation for 30 seconds with an Ambu bag. Bill 99440 and 99431 for providing ventilation.
Or, the baby has meconium prior to delivery and you are called to attend. You perform direct laryngoscopy of the baby (31515, laryngoscopy, direct; diagnostic [separate procedure]) and, if the meconium is very thick, perform intubation and suctioning (31500, intubation, endotracheal, emergency procedure). Bill either 31500 or 31515; you cannot bill both. Also report either 99440 or 99436.
Critical Care May Apply
Some babies who require resuscitation also require critical care. But for a newborn (up to 30 days) do not use the critical care codes; instead, CPT dictates use of initial neonatal intensive care (99295).
This raises the question of how to code when a newborn is being transported to another facility. For example, the baby born via c-section who needs resuscitation must be transferred to a hospital with a neonatal intensive-care unit. The pediatrician who attended the birth remains with the baby until the transport team arrives. If that pediatrician bills 99295, the receiving physician will not be able to bill that code again because it, like all the neonatal intensive-care codes, is a per-day code. Both physicians can bill for the code in two different settings, however, if there are two different provider numbers, says Charles Schulte, MD, FAAP, CPT advisor for the AAP.
If you believe that the payer will not pay two physicians for 99295, another option for the pediatrician awaiting transport for the patient is to bill a hospital admission plus prolonged services (+99356, +99357), recommends Richard A. Molteni, MD, FAAP, CPT editorial panel member. In addition, you can report all of the procedures you perform; with 99295, you can't because most will be bundled in to the global fee.
"Coding for an initial hospital visit and prolonged face-to-face time in lieu of the 99295 global would be the best bet," Molteni says. "It would also reimburse most appropriately for the work involved."
