Pediatric Coding Alert

Differentiate the four common types of pediatric hospital visits and you'll be on the road to correct coding.

While most pediatricians evaluate newborn inpatients as part of their regular weekly work, some practices struggle with how to code these services. But once you break it down into the four most common categories of inpatient E/M rounds, you could be sending claims out the door faster and more efficiently.

Check NICU Changes for 2012

Two of the most serious types of infant hospital visits involve time with intensive care or critical care. In both of these cases, the pediatrician has to go above and beyond what's required when seeing a healthy newborn--and coding these visits can be a challenge.

The issue of level of care provided is not specific to the site of service. However, neonatal critical and intensive care services are typically provided in a NICU.

Intensive care: Suppose a baby is tachypneic with a fever as a newborn and is worked up and treated for sepsis. The pediatrician provides a neonatal intensive level of care, performing daily intensive care services. In these situations you'll report a code from the 99477-99480 series of CPT®.

Critical care: When the pediatrician sees a patient for more severe issues--such as organ system failure or severe respiratory distress--he might determine that the patient is in need of critical care, which you'll code using the 99468-99469 series. In many cases, critical care would be managed by a neonatologist.

Changes for 2012: In the past, if a patient was transferred from neonatal intensive to critical care--or vice versa--the coding rules were unclear. However, CPT® 2012 cleans up that issue with parenthetical notes to guide you in making the correct code decision.

The AMA's CPT® Changes 2012 states, "New introductory language has been added to the inpatient neonatal intensive care services and pediatric and neonatal critical care service guidelines preceding code 99477 pertaining to the circumstance when the transfer of care of a sick neonate receiving intensive care services occurs from one physician to another physician in a different group, in which both providers will be providing intensive care services on the same date of service."

What CPT® now clarifies is that if an infant improves after the initial day and is transferred to a lower level of care, "the transferring physician does not report a per-day intensive care service." Instead, the transferring doctor will report a code from the subsequent hospital care section (99231-99233) of CPT®. The receiving physician will report subsequent intensive care (99478-99480) or subsequent hospital care (99231-99233) as appropriate based on the condition of the neonate or child," CPT® says.

If the physician delivers intensive care services but the patient becomes critically ill and is transferred to a different physician, "the transferring physician reports either the critical hourly care service (99291-99292) or the daily intensive care service performed, but not both," CPT® says. "The receiving physician reports subsequent inpatient neonatal or pediatric critical care (99469, 99472)."

"It's now very clear that when the admission to the hospital and the unit are the same day, it's always the initial code," said Peter A. Hollmann, MD, chair of the CPT® Editorial Panel, during the CPT® 2012 Annual Symposium in Chicago on Nov. 16. "The new rules make it clear when admission is from intensive care to critical care, the receiving physician will use a subsequent day critical care code."

Healthy Patient? Look to Well Care (99460-99463)

Fortunately, most newborns that pediatricians typically see in practice are healthy, and those services can be coded by selecting from the 99460-99463 series, which represent standard normal newborn per-day services.

A "normal" newborn has no medical conditions or need for special care. Report a normal newborn's history and examination with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant).

This code includes a maternal and/or fetal and newborn history, a newborn physical examination, meeting with the family, documentation in the record, and ordering any diagnostic tests or treatments.

In most cases, you'll report V30.x x (Single liveborn) as your diagnosis code in these instances.

Add-ons: Procedures such as circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes. Be sure to code the circumcision in addition to the newborn care. To indicate 99460-99463 is separately identifiable from the minor E/M included in surgical codes, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

'Stable Sick' Patients May Require 99231-99233

In some cases, a patient is in good health overall, but has some underlying issues that the physician has to spend more time evaluating. For instance, a newborn patient has jaundice that requires therapy. In these cases, you'll select the appropriate code from the 99231-99233 series, as supported by the pediatrician's documentation.

The codes in this series are not pediatric-specific, but can be billed for newborn services.