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Newborn E/M questions

jdibble

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I have a couple of questions my billing dept has due to insurance denials - if someone could help me that would be great. I'm pretty sure what the issue is, but I just would like to confirm as I'm not familiar with Newborn EM.

#1 - I have a hospitalist who billed 99464 Attendance at delivery and also 99460 Intial Care - newborn. The insurance is denying the 99464 as included in the 99460. I don't see that it was billed with -25 modifier. Would this be the reason for denial and if so, which code would get the modifier?

#2 - On another patient, the hospitalist billed 99462 subsequent normal newborn and then also billed 99468, Inital Neonatal critical care on the same dos. First they paid both charges, but now they are recouping the 99462 as incidental tp another procedure - would this also need the 25 modifier to pay - and again which code gets the modifier.

Thanks all for the assistance! :eek:

Jodi Dibble, CPC
 
Last edited:

lclarke

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Newborn E&M

Answer for #1 - It may depend on the insurance company that you are dealing with, however it is the norm in our office for BOTH 99464 and 99460 to be paid to our neonatal hospitalists when billed for on the same DOS
 

jdibble

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Does anyone know if I need to add 25 modifier to one of the neonatal visits for both to pay and if so which visit?

Thanks again!

Jodi Dibble, CPC
 

kjohnson

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I had posted this question in a couple different areas of this forum and have yet to recieve a reply. Since you are familiar with newborn coding, would you know the answer to my question?

I was wondering how to cpt code a newborn that is normal the first 2 days (99460 & 99462) and then on the 3rd day has tachypnea. Do we then code 99477 or 99480 or would it be 99221-99223?

Thanks so much!
 

jdibble

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Trying to help....

I actually am not familiar with newborn coding. I recently started coding for a group of Hospitalists and I am trying to correct errors that are being denied from the insurance - so I have been seeking answers to my question about why the Insurance is denying the code for the Attendance in the delivery room along with the initial newborn visit and an initial critical care visit billed with a subsequent normal visit - which seems on the same lines as your question.

I have read through the CPT book and it is just not clear which codes to use. In your case, for the 99477 - it is not clear at all what they mean by Initial hospital care. The first sentence says the code "represents the initial day of inpatient care for the child who is not critically ill, but requires intensive observation". Depending on how you read this, it would seem that the key word is INITIAL DAY of inpatient care, which would imply that would be the first day the patient was in the hospital. Being the third day is the day the baby developed Tachypnea, I would say that would not be the correct code. I would possibly say then that the Subsequent code, 99478-99480 - depending on the childs weight - would be used. I can honestly say that based on the CPT book, you would not use the 99221-99223 series. It states to use these codes for the Initiation of inpatient care of the ill neonate NOT requiring intensive observation, etc and since this visit is not the Initiation of the care and the patient needs intensive care, these codes are not approptiate. The 99231-99233 series would also not be used as I'm sure the baby is not more than 5000 grams and also again requires intensive care.

So, I think your correct choice would lie in the 99477-99480 series, but again, I would hesitate to use the Intial 99477 as I'm sure there was already an Initial visit on the date of birth. Unless someone can explain if the Intial is for the first day on the Intensive Care, regardless of the first day of hospital stay, I would use the subsequent codes.

I don't know if this helps at all - and if anyone who does know about Newborn patient coding could answer your question and mine, I know we would both appreciate it greatly! :)

Jodi Dibble, CPC
Professional Coder
Employed Physician Practice
Newton Memorial Hospital
 

kjohnson

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Thanks for your research on my question Jodi!! I really appreciate you taking the time to help me figure this out. :D
 
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Chattanooga, TN
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Updates??

I had posted this question in a couple different areas of this forum and have yet to recieve a reply. Since you are familiar with newborn coding, would you know the answer to my question?

I was wondering how to cpt code a newborn that is normal the first 2 days (99460 & 99462) and then on the 3rd day has tachypnea. Do we then code 99477 or 99480 or would it be 99221-99223?

Thanks so much!

Are there any updates on this if i am reading this correctly this is from 8 years ago and the question is arising in my office.. To add to the question could you also use (for the 3rd day with problems) CPT code 99356 or 99357?? I was unsure if these codes could be used for newborns. Thank you, Holly
 

caroline

Guru
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I have a couple of questions my billing dept has due to insurance denials - if someone could help me that would be great. I'm pretty sure what the issue is, but I just would like to confirm as I'm not familiar with Newborn EM.

#1 - I have a hospitalist who billed 99464 Attendance at delivery and also 99460 Intial Care - newborn. The insurance is denying the 99464 as included in the 99460. I don't see that it was billed with -25 modifier. Would this be the reason for denial and if so, which code would get the modifier?

#2 - On another patient, the hospitalist billed 99462 subsequent normal newborn and then also billed 99468, Inital Neonatal critical care on the same dos. First they paid both charges, but now they are recouping the 99462 as incidental tp another procedure - would this also need the 25 modifier to pay - and again which code gets the modifier.

Thanks all for the assistance! :eek:

Jodi Dibble, CPC
Hi Jodi-As per the CPT book under Inpatient Neonatal and Pediatric Critical Care pg.46: When a newborn becomes critically ill on the same day they have already received normal newborn care (99460,99461, 99462), and the same individual or group assumes critical care, report initial critical care service (99468) with modifier 25 in addition to the normal newborn code Hope this answers your question #-2.

Caroline
 
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It is important when coding for ill neonates that you confirm the level of care the patient required. Never report intensive care codes if the patient doesn't require the intensive monitoring and frequent interventions. Newborns can be ill but only require care at the level of 99231-99233. An article in the American Academy of Pediatrics magazine give some examples of each. https://www.aappublications.org/content/29/9/38

Also, note that code edits may contradict CPT on reporting of normal newborn care and critical care on the same date of service. A payer may require a modifier on code 999460 rather than 99468 or may just not allow both services on the same date. Be sure to look online for a reimbursement policy for the individual payer as they often advise about these types of issues.
 
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