Scott D. Duncan, MD, MHA
Neonatal intensive care requires a combination of medical management and procedural skills. Care can occur within several different settings, ranging from the delivery room to the intensive care unit. Reimbursement is based upon proper documentation, supporting the (Current Procedural Terminology (CPT®), and International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10) codes.
The astute neonatologist and/or advanced practice provider (APP) should understand common CPT® code sets and their appropriate use. Many practices expect the provider to enter the correct CPT® code into a charge capture system, which is ultimately transmitted to the payor. Yet many physicians and APPs do not understand the nuances of the daily code in combination with procedural coding.
In an effort to encourage correct coding and reduce inappropriate payments, the Centers for Medicare & Medicaid Services (CMS) instituted a National Correct Coding Initiative (NCCI) .1 Procedure-ToProcedure (PTP) edits were first implemented in 1996 and consists of incorrect code combinations.1 This information is updated quarterly and available via CMS at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits. Billing software should incorporate a transaction edit system, highlighting errors in the claim prior to submission and integrating NCCI edits. Billing for several services that should be incorporated into a single service is considered fraud!
Typical CPT® codes used in the daily management of the ill neonate include the critical care code set (99468-99472) and the intensive care code set (99477-99480). The critical care and intensive care CPT® codes are considered global codes, that is “most services provided throughout the day in the usual cases of neonatal care are factored into the value of those codes and therefore are bundled or not billed separately.”2 A partial list of procedures which are considered bundled can be found in Table 1.
There are limited procedures that are not considered part of the global critical care or intensive care codes. Most of these procedures require additional work beyond that of the daily management of the neonate. An abbreviated list of procedures that may be billed in addition to the global codes is found in Table 2.
Two unique situations exist where procedures are not bundled into the CPT® code set. These include the use of time-based (hourly) critical care codes (99291-99292) and the delivery room resuscitation code (99465). The typical use of a time-based code occurs in the scenario where a critically ill neonate is being transferred to a NICU in the care of a different group of physicians, or critical care is being provided by a second physician of a different specialty. None of the common procedures found in Table 1 are considered bundled when using time-based critical care codes; however, the time for the procedure must be subtracted from the total time in which critical care was provided. Please refer to the latest NCCI edits and/or guidance from the payor for a comprehensive list of procedural codes that may be billed separately when using time-based critical care codes.
Within the delivery room, common procedures associated with resuscitative efforts may include intubation, surfactant administration, thoracentesis, paracentesis, and umbilical vein catheterization. In the event that a neonate requires resuscitation, the appropriate CPT® code would be 99465. Other procedures performed in the delivery room should be reported separately; however, the procedure must be performed as an essential component of the resuscitation. These procedures may include emergency endotracheal intubation (31500), catheterization of the umbilical vein (36510), catheterization of the umbilical artery (36660), and surfactant administration (34610).
Correct coding and documentation support the business aspects of the practice of neonatology, in all its variations and employment models. The neonatal care practitioner should have knowledge of correct coding, selecting the correct code(s) for the care provided. Further, the practitioner should know when to bundle or unbundle the baby!
Question
You are asked to attend an emergency cesarean delivery of a 24-week estimated gestational age neonate with a concerning fetal heart rate tracing and preterm rupture of membranes. The neonate is born limp, with poor respiratory effort, low heart rate, and cyanosis. Following NRP guidelines, you provide bag mask ventilation. Subsequently, the neonate requires intubation and positive pressure ventilation. Heart rate is less than 60 beats per minute, and cardiac compressions are started. An umbilical venous catheter is placed, and the neonate is given epinephrine. The infant was slow to recover, and surfactant is given as part of the resuscitative effort. Once stabilized, the infant is moved to the NICU, where an umbilical arterial catheter is placed. What is the correct code(s) for the delivery room?
- A. 99465
- B. 99465, 31500, 36510
- C. 99465, 31500, 36510, 36660
The correct answer is B
99465 represents the code for delivery or birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output.
31500 represents the code for endotracheal intubation, emergency procedure.
36510 represents the code for catheterization of the umbilical vein for diagnosis or therapy in the newborn.
36660 represents the code for catheterization of the umbilical artery for diagnosis or therapy in the newborn. As this procedure was performed in the NICU, this procedure is not billable as part of the resuscitation, nor as part of the initial day of critical care.
References:
- National Correct Coding Initiative Edits. Centers for Medicare & Medicaid Services. https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd. Accessed May 13, 2020.
- A Quick Reference Guide to Neonatal Coding and Documentation. American Academy of Pediatrics; 2016.