Pediatric Coding Alert

Look to definitions for definitive documentation.

The birth of a child, and the days that follow, can be both joyful and stressful if you're a parent. They can also be a source of stress for coders, who have to sort through a number of evaluation and management (E/M) code options to document services their pediatrician performs in the first days of a child's life.

So, we've assembled this useful guide to the key codes you will need for quick and accurate neonatal coding that covers the first 28 days of a newborn's life.

Define Services for Delivery Codes

For coders, a child's birth essentially boils down to a choice of two CPT^® codes:

• 99464 - Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn or 
• 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.  

Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California, advises coders that they will need to determine whether their provider has performed stabilization or resuscitation. "With 99464," she elaborates, "the provider is providing stabilization of the newborn, whereas the provider is performing actual resuscitation with specified ventilation and chest compression in 99465."  

Define Days for Care, Minutes for Discharge

For normal newborns, there are four codes you can use to describe the kind of services your pediatrician could provide right after birth, along with two other time-based codes to document the newborn's discharge:

• 99460 - Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant
• 99461 - Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center
• 99462 - Subsequent hospital care, per day, for evaluation and management of normal newborn
• 99463 - Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date
• 99238 - Hospital discharge day management; 30 minutes or less
• 99239 - ... more than 30 minutes 

Coding combo: One code, 99463, handles both care and discharge if they occur on the same day.

Define Weight for Intensive Care

These newborn E/M codes use the words "normal newborn," which are key terms for coders to understand. While CPT^® defines "newborn" or "neonate" as a child less than 28-days-old, it does not offer a definition of "normal."

To aid coders, Donelle Holle, RN, President of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana, advises that "'normal' typically means that there are no extra tests, evaluation, or monitoring of the neonate."

So, as Johnson puts it, when the neonate "does require intensive observation or frequent intervention," but not critical care, you would reach for one of the neonatal intensive care codes:

• 99477 - Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services,
• 99478 - Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams),
• 99479 - ... (present body weight of 1500-2500 grams), or
• 99480 - ... (present body weight of 2501-5000 grams).

Coding alert: Holle reminds coders that they must document the neonate's weight, as these intensive care codes have specific body weights built in to their descriptors.

Define Deterioration, Dx for Critical Care

CPT^® describes critical illness as impairing "one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition." Should the neonate's condition deteriorate in this way, coders would then have two more inpatient codes and two general E/M codes, which can be used in both inpatient and outpatient encounters, to choose from.

• 99468 - Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger
• 99469 - Subsequent inpatient neonatal critical care ...
• 99291 - Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
• 99292 - ...each additional 30 minutes (List separately in addition to code for primary service)  

Coding reminders: Holle notes that "diagnosis coding will be vital when billing any of these special pediatric codes, especially if the neonate is critically ill." And » Johnson adds that "the coder needs to be familiar with the various timelines and changes in the level of care for the newborn. When the newborn changes from critical care, to intensive care, to a lower level bed," Johnson concludes, "the coding changes are affected by times and dates."