Please help - 68. A neonate was born at 36
68. A neonate was born at 36 weeks gestation and weighed 1965 grams. At birth, the obstetrician suspected
Downs syndrome (eg, trisomy-2l). A comprehensive history of the mother's preg-nancy and the
birth, as well as a comprehensive examination of the neonate, were documented. Presence of characteristics
associated with the chromosomal anomaly (eg, flaccid muscle tones), limbs comparatively short
for gestational age and as compared to trunk size, relatively flat nose bridge, were noted. Based on the
low birth weight and these suspicions, and despite the lack of noticeable physical distress (Apgar scores
were 4, 7 and 9 at 1, 5 and 10 minutes, respectively), the neonate was taken to the NICU for monitoring
and tests to examine the heart due to the prevalence of cardiac anomalies common to the syndrome.
Medical decision making was documented as moderate. The obstetrician performed an ultrasound,
which revealed a minor atrial septal defect, ostium secundum type. This finding did not necessitate immediate
surgery to correct the defect. A genetic test confirmed the diagnosis of nonmosiac trisomy- 21.
The infant was transferred from NI CU on day 2 to regular neonatal care where an expanded problem
focused interval history and expanded problem focused exam were performed with medical decision
making of moderate complexity. On day 3, a problem focused interval history and problem focused examination
we re performed with low complexity medical decision making. On day 4, the neonate was
discharged to home after the obstetrician spent 45 minutes with the parents giving instructions on how to
deal with the child's ongoing developmental issues and care. During the baby's hospital stay, the parents
also met with the hospital's genetic counselor who provided family support contact information.
The obstetrician scheduled a 15 minute weekly appointment for the next six weeks to monitor the infant's
progress. Code the obstetrician's services and the diagnoses for the neonate.
Day 1 Day 2 Day 3 Day 4
99222, 76604-26 99232 99231 99239
My question is that why I cannot code 99477 on the day 1 instead of 99222 ?
Real life vs Test scenarios
In real life, in our hospital, such a child would have been admitted by the neonatologist in charge of the NICU and s/he probably would have documented and used the 99477 code for that initial day's service.
But in this test scenario there are several clues that lead you away from that.
First you have: despite the lack of noticeable physical distress This is telling me that the baby was doing fine.
Secondly: taken to the NICU for monitoring and tests The word "intensive" is missing from this statement. 99477 requires intensive monitoring.
I do not think it is a particularly good test question. However, this is a good example of the coder's need to code ONLY what is actually documented and not read too much into the scenario.
Hope that helps you.
F Tessa Bartels, CPC, CEMC
Last edited by FTessaBartels; 12-18-2009 at 10:43 AM.
Isn't the word "intensive" included in the acronym "NICU" ??? Therefore, the word is not really missing from the statement at all... at least this is how it seems to me, but this is not my area of expertise.
Originally Posted by FTessaBartels
A patient may be in the NICU for a variety of reasons including, but not limited to, the facility's standard of care/ward assignment based on patient gestational age.
Just as not every patient in the ICU or CCU is actually critically ill or receiving critical care, not everyl baby in the NICU is receiving intensive monitoring.
Like I said before, the question itself is not a good one. But physicians MUST document clearly in order for the coder to assign the correct code.
Hope that helps.
F Tessa Bartels, CPC, CEMC
Last edited by FTessaBartels; 12-18-2009 at 11:03 AM.
That would be the equivalent of saying all patients in ICU are receiving critical care and should be coded as 99291, 99292. Place of service does not determine these types of services which is probably part of the goal of the question itself.
I agree not the best question but it does make you think which is good.
Laura, CPC, CEMC