Neonatology Coding

Basic Coding Concepts Improper Coding: Coding for services and procedures that cannot be substantiated by the documentation in the medical record Coding for levels of services which cannot be substantiated by documentation in the medical record Sloppy = Unsubstantiated Payment Denial Intentional = “Fraud and Abuse” Legal/Fine/Prison

General E&M Principles Medical record should be complete & legible The documentation of an encounter should include: Chief complaint and/or reason for encounter; relevant history, physical exam and prior diagnostic tests Assessment, impression or diagnosis The present & past diagnoses and conditions including prenatal & intrapartum for neonate Patient’s progress, response to and changes in treatment, planned follow-up instructions and diagnosis

COUNSELING AND CONSULTATION CODES

Perinatal Consultation Code Outpatient or inpatient When the amount of counseling time during a patient encounter accounts for more than 50% Also called: Confirmatory Consultation *You must note time on the consult form/note. Billing is based on time in 15 min. increments

INPATIENT CONSULTATION – REFERRED BY ANOTHER PHYSICIAN The information needed in the chart. The request and reason for the consult from the referring physician, (can be written or oral) The services ordered The opinion rendered A written report to the referring physician

NEONATAL TRANSPORT AND DELIVERY ROOM SERVICES

Neonatal Transport Code only on day of transfer Supervision Physician direction of emergency medical systems emergency care, advanced life support. Document Supervision Communication Involvement in decision making Procedures

Delivery Room Services 99436 Attendance at delivery (when requested by the delivering physician) and initial stabilization of the newborn (includes blow-by oxygen, stimulation, suctioning) 99440 Neonatal resuscitation requiring positive pressure ventilation and/or chest compressions * may include intubation (31500) * airway suctioning (31515) * umbilical catherization (36510-vein; 36660-artery) * may be used IN ADDITION to initial day codes

“PHYSICIAN STANDBY SERVICES” 99360 Prolonged physician attendance, each 30 minutes In the past the wording of this code included “for newborn care.” The phrase “For newborn care” has been removed from 99360 Use the new “Attendance at Delivery” code (99436). Other circumstances where prolonged standby is required (eg, during surgery in NICU, fetal surgery) could be listed if present during the procedure and requested by the surgeon or anesthesiologist and documented in the medical record. Code has no assigned RVU value.

Teaching Attending: Definitions Direct Services A service to an individual patient furnished by a physician or by a resident under the supervision of a physician in a teaching hospital Must document the service furnished, the participation of the teaching physician and whether they were present in the same room

Teaching Attending: Must Show Involvement Teaching physician must show: Personal involvement in the: Evaluation Development of the plan of care Treatment of the patient Cannot just co-sign resident, fellow or NNP note: “Agree with above and plan as written”

Teaching Attending: Determining Level of Service Teaching physician must be present during/at the time when the level of service is determined May be at the bedside with the resident/fellow or the NNP May examine the patient independently Must document their presence

Documentation I was present with resident, fellow or NNP during H&P. I discussed and agree with findings and plan. or I examined the patient. Discussed with resident, fellow or NNP and agree with findings and plan.

Medical Decision Making The assessment and plan for each problem should be documented and include: the status/severity of the problem risk of complications & deterioration amount and complexity of data differential diagnoses diagnostic and therapeutic tests, procedures treatment plan and interventions

Low Complexity Decision Making Problem is low severity, urgency Low risk of clinical complications Limited differential diagnoses Limited review of pertinent data straightforward diagnostic / therapeutic interventions 2/3 elements must meet or exceed the requirement for low complexity

Moderate Complexity moderate severity problem; low to moderate risk of clinical deterioration requires review of detailed amount of additional information extended differential diagnosis complicated diagnostic / therapeutic interventions complicated treatment plan Initial 50 min., subsequent 25 min.

High Complexity problem of high severity high risk of complications high risk of clinical deterioration excessive differential diagnoses highly complex & multiple diagnostic and therapeutic interventions highly complex treatment plan Initial 70 min, subsequent 35 min.

Critical Care Services Critical care is the direct delivery by a physician of medical care for a critically ill patient. A critical illness acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration. Critical care involves high complexity decision making to assess, manipulate and support vital system functions to treat single or multi-system failure Critically ill neonates require cardiac/respiratory support including ventilator or NCPAP when indicated Continuous or frequent vital sign measurement Laboratory and blood gas interpretations Follow up physician evaluations Immediate pre-operative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included Examples of vital organ system failure include, but are not limited to: CNS failure Shock Circulatory failure Renal, hepatic or metabolic failure Respiratory failure

Critical Care Services (cont.) Critical care typically requires interpretation of multiple physiologic parameters and/or application of advanced technology, critical care may be provided when these elements are not present. Critical care may be provided on multiple days, even if no changes are made in the treatment provided the patient’s condition continues to require the level of physician attention. Providing medical care to a critically ill patient qualifies as a critical care service only if both the illness and the treatment being provided meet the requirements.

Critical Care Services (cont.) Critical care is not established simply by the presence of any of the following: Birth weight or postnatal weight (except 99298 and 99299) Gestational age Apgar score Type of unit where infant is cared for Need for isolette Oxygen need Requirement for IV fluids or hyperalimentation Bronchodilator use Antibiotic therapy Corticosteroid therapy Phototherapy Apnea and bradycardia Gavage or G tube feeds

KEY WORDS TO DETERMINE CRITICAL CARE IMPAIRS ONE OR MORE VITAL ORGAN SYSTEMS HIGH PROBABILITY OF DETERIORATION HIGH COMPLEXITY DECISION MAKING ASSESS, MANIPULATE, SUPPORT VITAL SYSTEM FUNCTION(S) TREAT ORGAN SYSTEM FAILURE PREVENT FURTHER DETERIORATION

KEY WORDS TO DETERMINE CRITICAL CARE CARDIAC AND/OR RESPIRATORY SUPPORT WHEN INDICATED CONTINUOUS OR VITAL SIGN MONITORING LABORATORY AND BLOOD GAS INTERPRETATIONS FOLLOW UP PHYSICIAN RE-EVALUATIONS CONSTANT OBSERVATION OF HEALTH CARE TEAM PHYSICIAN SUPERVISION

Neonatal Critical Care Codes (0 - 30 d) The “Global” Codes: 99295: Initial neonatal critical care 99296: Subsequent neonatal critical care Pediatric Critical Care Codes (31 d – 24 mos) The “Global” Codes: 99293: Initial pediatric critical care 99294: Subsequent pediatric critical care

NEONATAL INTENSIVE CARE “Bundled Neonatal Services” umbilical lines peripheral lines central lines gastric tubes intubation lumbar puncture blood gas interpretation bladder catheter surfactant administration ventilator management bladder tap CPAP/N-CPAP transfusions vascular puncture PFT testing (flow loops) vital sign monitoring pulse oximetry IV fluid & TPN

Intensive (Non-Critical) Low Birth Weight Services The “Global” Codes: 99298: Subsequent intensive care for evaluation/management of the recovering very low birth weight infant (present body weight <1500 grams) 99299: Subsequent intensive care for evaluation/management of the recovering low birth weight infant (present body weight 1500 - 2500 grams) “…requires intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, lab or oxygen monitoring and constant observation by the health care team…”

Day of Discharge Codes The Rules: Used to report total duration of time spent by a physician for final hospital discharge of a patient. Include final exam of patient, discussion of hospitalization, instructions for continuing care to care-givers Preparation of discharge papers, prescriptions, referral forms The codes: 99238: Hospital discharge management: 30 minutes or less (rare) 99239: Hospital discharge management: More than 30 minutes

Conference Codes (Can be used with bundled codes) 99361 – Medical conference by a physician with an interdisciplinary team of health care professionals ~ 30 minutes 99362 – Medical conference by a physician with an interdisciplinary team of health care professionals ~ 60 minutes 99356 – Family conference first 60 min. 99357 – each additional 30 min.

OTHER USEFUL CODES 11200 – Ligation extra digit 31500 – Endotracheal Intubation 31515 – Laryngoscopy with aspiration 31520 – Diagnostic laryngoscopy 32000 – Thoracentesis 32020 – Chest tube 36488 – Central Venous catheter 36510 – UVC – Catheter 36600 – Arterial puncture 36620 – Percutaneous art line 36490 – Venous Cut Down 36450 – Exchange transfusion 36660 – UAC Catheter 51000 – Bladder tap 51701 / 51702 – Bladder Cath 54150 - Circumcision 61020 – Ventricular tap 62270 – Spinal tap

Coding Questions 2004 Example 1: Baby Kraybill is a 1800 gram infant born by vaginal delivery on 07/31/04 with APGAR scores of 7, 9. He initially has mild respiratory distress and is admitted to the NICU and placed in a hood at 35% oxygen. Catheters are not placed. The baby is placed on antibiotics. On 08/01/04 the baby is on nasal cannula oxygen at (100% FiO2 with ½ liter flow) and TPN is started. He remains on nasal cannula oxygen and small feedings are started on 08/02/04. The baby is placed under the bilirubin lights on 08/02/04 and oxygen is stopped on 08/07/04. His weight on 08/07/04 is 1900 grams.

Coding Questions Example 1: 1. The code (s) for 07/31/04: a. 99222 (Moderately complex) b. 99223 (Highly complex) c. 99295 (Critical Care) 2. The code (s) for 08/01/04 – 08/07/04 : a. 99233 (Highly complex) b. 99296 (Critical care 2-30 days) c. 99299 (Intensive care 1500-2500g)

Coding Questions Example 2: Baby Lawson is a 1430 gram infant in an isolette on Day 13 of life (08/13/04). He is on nasal cannula oxygen (100% ¼ liter flow). He is also on caffeine for self resolving apnea of prematurity, diuretics for mild lung disease and Epogen for anemia. The code for 08/13/04: a. 99296 (Critical care 2-30 days) b. 99233 (Highly complex) c. 99298 (Intensive care < 1500g)

Coding Questions Example 3: Baby Rojas is born at 38 weeks gestation on 10/31/04 weighing 2600 grams. There is a maternal history of chorioamnionitis for which she received intrapartum antibiotics. Dr. Price attends the delivery, does not provide positive pressure ventilation and admits the infant to the NICU. The baby has respiratory distress, and a blood culture, a chest x-ray and a spinal tap is done. The mother had previously experienced a neonatal loss with GBS Sepsis. The family is extremely anxious and Dr. Price spends one hour with the extended family discussing the admission, status and plans. The infant loses 200gm, is treated with antibiotics and maintains an oxygen requirement by hood until 11/03/04. He remains NPO until 11/2/04.

Coding Questions Example 3: 1. The code (s) for 10/31/04: 99436 (Attend delivery) 99223 ( Initial,Highly complex) 99295 (Initial, Critical Care), 99222 (Moderately Complex) 62270 (LP) 99356 (Family conference) 2. The code (s) for 11/02/04: 99232 (Subsequent day, Moderately Complex) 99233 (Subsequent day, Highly Complex) 99299 (Subsequent day, Intensive Care 1500-2500g)   Example 10: a. The code (s) for 10/31/04: 99223: Admit High Complexity – Comprehensive history 62270: Spinal tap For extended time for conference with family could use: -21 Modifier: Prolonged E/M Service (when service provided is greater than usually or 99358 - 99359: Prolonged Physician services without direct “face to face” patient contact b. The code (s) for 11/01/04: 99232: Subsequent hospital care, expanded problem/ moderate complexity 99233: Subsequent hospital care, detailed history, high complexity c. The code (s) for 11/02/04: Teaching points: Possible alternatives for prolonged time involvement Some discussion about day when decision needs to be made between 99232 vs 99233

Coding Questions Example 4: Baby Clingenpeel is a 30 day old infant who weighs 2460 grams on 10/31/04. The baby was initially diagnosed with RDS that resolved and by 10/31/04 was a growing infant on no medications except for vitamins. On 11/01/04, the baby became apneic, mottled, was intubated and a PICC is placed. He remained on a ventilator until 11/04/04. He was then placed on NC oxygen and feeds were re-started. The baby’s weight on 11/04 was 2485 grams.

Coding Questions Example 4: 1. The code (s) for 10/31/04: a. 99298 (Intensive Care < 1500g) b. 99299 (Intensive Care 1500-2500g) c. 99233 (Highly complex) 2. The code (s) for 11/01/04: a. 99296 (Critical Care 2-30d), 36568 (PICC) b. 99294 (Critical Care > 30 d), 36568 (PICC) c. 99299 (Intensive Care 1500-2500g), 36568 (PICC) 3. The code (s) for 11/04/04: a. 99296 (Critical Care 2-30d) b. 99294 (Critical Care > 30d) c. 99299 (Intensive Care 1500-2500g)   Example 12: a. The code (s) for 10/31/04: 99299: Subsequent visit - 1500-2500 grams b. The code (s) for 11/01/04: 99296: Critical care – subsequent day(s) c. The code (s) for 11/02/04: d. The code (s) for 11/03/04: 99294: Subsequent pediatric critical care, 31 days up through 24 months of age e. The code (s) for 11/04/04: Teaching points: Use of Pediatric critical care codes at 31 days

Coding Questions Example 5: Baby Pearson is a near term infant weighing 2800 grams born on 10/31/04 at 11:00 PM by C-Section for fetal distress. An NNP attends the delivery, provides positive pressure ventilation and admits the patient to the NICU. An IV is placed and the baby is placed in a hood in 30% oxygen. The neonatologist is asleep in the call room. On 11/01/04 the neonatologist examines the patient and discusses her with the NNP. The NNP is employed by the neonatal group.

Coding Questions Example 5: 1. The code (s) for 10/31/04: 99436 (Attend delivery) 99440 (Resuscitation) 99223 (Initial day Highly Complex) 99295 (Initial day, Critical Care 0-30d) No Charge 2. The code (s) for 11/01/04: 99296 (Critical Care, subsequent day) 99223 (Initial day, Highly complex) 99233 (Highly complex, subsequent day)   Example 15: a. The code (s) for 10/31/04: 99440: Neonatal resuscitation at delivery (Billed for the NPP) 99223: Admit High Complexity – Comprehensive history (Billed for the NPP) b. The code (s) for 11/01/04: 99233: Subsequent hospital care, detailed history, high complexity (Billed for the physician) c. The code (s) for 11/02/04: 99233: Subsequent hospital care, detailed history, high complexity (Billed for the NPP) Teaching points: Shared billing with a NPP who works for your group and who has their own PIN number. Emphasizes need for face to face contact for the physician to bill for a service

Coding Questions Example 6: Baby Gordon is born by C-Section due to fetal distress on 10/31/04. There is thick meconium at delivery. The neonatal fellow attends the delivery, intubates and suctions the trachea, places a UVC and performs positive pressure ventilation in the DR. Dr. Bose sticks his head into the DR, asks if everything is OK and waits until the fellow says that the baby is stable before leaving. The baby is admitted to the NICU and placed on a ventilator. The fellow writes the note and Dr. Bose examines the patient and writes a brief note referring to the fellow’s note.

Coding Questions Example 6: 1. The code (s) for 10/31/04: 99436 (Attend at delivery) 99440 (Resuscitation) 99295 (Initial day Critical Care) 99223 (Initial day Highly Complex) 31500 (Intubation) 31515 (Laryngoscopy with aspiration) 36510 (UVC)   Example 18: a. The code (s) for 10/31/04: 99440: Neonatal resuscitation at delivery (If physician feels he was there for key portion of the encounter) 99295: Critical care code admission day Teaching points: Billing if there for key part of the service. Uses combined note to meet criteria if critical condition documented

Coding Questions Example 7: This case is identical to #6 but Dr. Bose is in the DR and supervises the fellow. He remains in the DR and under his supervision the infant is intubated for meconium but does not require subsequent intubation, lines or positive pressure ventilation in the DR. He examines the patient and refers to the fellow’s note in writing his own admit note. Four hours after admission the patient requires intubation. A UVC is attempted at that time and is unsuccessful. The NNP places a PICC that is not central. The fellow removes that line and replaces it with a central PICC.

Coding Questions Example 7: The code (s) for 10/31/04: 99436 (Attend at delivery) 99440 (Resuscitation) 99295 (Initial day Critical Care) 99223 (Initial day Highly Complex) 31500 (Intubation) 31515 (Laryngoscopy with aspiration) 36510 (UVC) 36568 (PICC)   Example 18: a. The code (s) for 10/31/04: 99440: Neonatal resuscitation at delivery 99295: Critical care code admission day Teaching points: Billing if there for key part of the service. Uses combined note to meet criteria if critical condition documented