Pediatric Coding Alert

'Normal' newborn codes may not always be the most appropriate for your patients.

CPT^® maintains a large number of available codes for initial newborn services, making it a challenge to always select the right one. If you find yourself getting tripped up by the multiple categories, read on for some expert tips and real-world examples that will point you in the right direction.

'Normal' Care Refers to No Additional Diagnoses

A "normal" newborn has no abnormal 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).

Initial newborn care for a normal infant typically includes a maternal and/or fetal and newborn history; a newborn physical examination; ordering diagnostic tests and treatments; meetings with the family; and documentation in the medical record.

Diagnosis tip: When billing with 99460, include diagnosis V30.x x (Single liveborn). Because 99460 states "normal newborn," you cannot have any other diagnosis for that CPT^® code.

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 (99460-99463). These codes have zero day global periods. Be sure to code the circumcision in addition to the newborn care. To indicate 99460-99463 is significantly 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) to 99460-99463.

Sick Newborn Needs Inpatient Codes

When the pediatrician provides E/M services for newborns who are not considered "normal," CPT^® directs you to report the codes for hospital inpatient (99221-99233), neonatal intensive (99477-99480), or critical care (99468-99469) services.

A baby considered a "sick" newborn might have a fever, high hemoglobin count, or mild respiratory distress. For a sick newborn, you'll select from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) for the first day of care, based on the level of history, examination, and medical decision making.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The physician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn's care with the appropriate choice from 99221-99223.

Intensive Care Require Extra Monitoring

Sometimes infants and neonates are not critically ill but need intensive cardiac or respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, nutritional adjustments, or laboratory and oxygen monitoring. These babies also require constant observation by the health care team under direct physician supervision.

In these situations, remember that the level of care delivered -- not the site of service -- determines the code you choose. Intensive care codes could apply to a baby in the newborn nursery or NICU.

Example: An infant is born at 37 weeks gestation with mild tachypnea and requires 30 percent O2 by nasal cannula. The pediatrician acquires cultures and initiates IV antibiotics. Close monitoring is maintained; no additional intervention is indicated.

For the first day of this baby's care, report 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). Additional days should be coded according to the infant's status as follows:

If the neonate continues to require intensive monitoring, frequent interventions, observation, or other intensive care services, use the low birth weight or recovering infant codes. Choose from 99478-99480 (Subsequent intensive care, per day, for the evaluation and management of the recovering infant ...), based on the infant's weight.

If the child is still ill but no longer requires intensive or critical care services, select from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...).

Sometimes a child moves from being intensively ill to being ill, to being well. Once the child is well, turn to 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn).

Critical Care Codes Follow Days

Neonates are classified as meeting critical care status when they have organ system failure or progression of organ system failure such as severe respiratory distress, hypotension, or sepsis.

Example: A 32-week premature infant develops moderate respiratory distress and requires treatment of premature lung disease (RSD, respiratory distress syndrome) and nasal CPAP. Respiratory failure rapidly progresses and the physician initiates ventilator treatment.

As with intensive care coding, you have one code for the initial day of neonatal critical care treatment and additional codes for subsequent days. Start with 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) and report 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for each additional day.

Remember: If a normal or ill newborn becomes critically or intensively ill subsequent to the initial H&E or hospital admission, treat the ICU or NICU admission as initial. You always code for an "initial" day of critical care or intensive care before you can use a "subsequent" day code. In other words, a patient cannot go from a "regular" or sick first or second day code to a subsequent critical or intensive care code.

Outlying hospital transfers: If a critically ill infant is cared for in an outlying hospital, and transferred to a neonatal intensive care setting, the initial managing physician should code initial hour and subsequent additional 30 minute critical care codes (99291, Critical care first hour; +99292, Critical care each additional 30 minutes). The accepting facility would then bill the global neonatal critical care codes.

Note: Many procedures are included in neonatal critical care codes. Refer to the 2011 CPT^® book for a list of these procedures do not "double bill" these procedures.