Pediatric Coding Alert

When pediatricians provide services for newborns going in and out of the neonatal intensive care unit (NICU), proper coding depends as much on documenting who performs a service as it does on documenting what service is performed. Consider the following scenarios to avoid incorrectly reporting the pediatrician's services and double-billing for the neonatologist's services. Pediatrician Handles All Noncritical Care Sometimes the baby is born without problems, later becomes ill, goes to the NICU and returns to the regular nursery. The pediatrician handles all of the patient's care and codes accordingly. For example, suppose an obstetrician delivers a baby who is admitted to the nursery by the pediatrician. On day one, the pediatrician finds that the baby is normal. On day two, the infant develops tachypnea. The pediatrician is called, and he examines the infant. For the admittance to the nursery on day one, the pediatrician assigns the normal newborn examination code 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]). For the examination on day two, the day of the illness, he bills the appropriate level of subsequent hospital care (99231-99233), linked to the diagnosis code for tachypnea (770.6 ). Do not report subsequent hospital care for the normal newborn (99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day) for this visit, because the baby is now abnormal, says Richard Molteni, MD, FAAP, a neonatologist and medical director of Children's Hospital and Regional Medical Center in Seattle. In addition, you should not bill an initial hospital care code (99221-99223) because the pediatrician already examined the newborn in the hospital. Therefore, the service constitutes subsequent care, not initial care. When the pediatrician discharges the infant, report a hospital discharge (99238, Hospital discharge day management; 30 minutes or less; 99239, more than 30 minutes). Neonatologist Provides Critical Care Only However, if the baby's condition is more severe, requiring critical care in the NICU, the neonatologist may assume care. In this case, the neonatologist rather than the pediatrician reports the services in the NICU. For example, suppose the baby goes to the normal nursery after birth, but on day two develops signs of sepsis, is critically ill, and is transferred to the NICU where the neonatology unit takes over the care. If on day two the pediatrician assesses the baby for illness, he can charge for his services as a 99233 (highest level of subsequent hospital care) with procedures prior to transfer to the neonatologist (99295, Neonatal intensive care). The insurance company could question this, so it might need to be appealed with documentation. Although the [...]