Pediatric Coding Alert

When a sick or premature newborn becomes your patient, and you care for the baby but there is no neonatal intensive care unit (NICU) i.e. you are just managing the care in a regular nursery or pediatric ward can you still use the neonatal intensive care codes? And are they for low birth weight babies only, or for any critically ill newborns? These questions come from Manzar Momen, office manager for Pediatric Associates, a two-pediatrician practice in Bridgeport, WV.

Level of Service, Not the Site

First of all, the neonatal intensive care codes (99295-99298) are not NICU codes. The wording in CPT was changed to reflect the fact that these codes can, indeed, be used for critically ill neonates, regardless of the place of service, says Richard H. Tuck, MD, FAAP, a practicing pediatrician in Zanesville, OH, and a regional coding resource for the American Academy of Pediatrics. These codes are not only for use in NICUs, says Tuck, who is also a founding member of the AMA RBRVS RUC. They are for all critically ill neonates. Furthermore, Tuck notes, that not all babies in NICUs should get the neonatal intensive care codes. Sometimes you just use regular hospital codes (99221-99233) while a baby is in the NICU, he adds. Lets say the baby was born with grunting respirations and respiratory distress that requires oxygen, a septic workup, and treatment with antibiotics. That is a sick newborn who might be managed in a NICU, but with the hospital care codes, Tuck explains.

Tip: Sometimes the reimbursement is better if you do use the hospital care codes and add on the procedures you do, rather than using the neonatal intensive care codes, which include most of those procedures, says Tuck. Thats because most insurance companies are better at paying for procedures, he says. This is true for Medicaid in Ohio, for example, where reimbursement is very low for neonatal intensive care codes.

Low Birth Weight

The neonatal intensive care codes, with the exception of 99298, are for infants of any weight, says Tuck. The confusion about whether there is a weight restriction comes from the introduction of 99298, which is a new code for the recovering very low birth weight infant. These newborns weigh less than 1500 grams at birth. The other neonatal intensive care codes, however, apply to critically ill newborns.