Lisa Owens, DO

Like firefighters, neonatologists must be ready to “put out a fire” anytime. While we are clinically prepared for the necessary interventions, we may feel less prepared for coding such events. Understanding what was done, what was submitted before the emergency, and which codes have procedures bundled or when 24-hour global codes apply can help.

Scenario #1

The hospital delivery team (NICU RN and RT) attends a routine C/Section of a term infant as per hospital policy. At 15 minutes of life, the neonatologist on call receives a call from the RN because she is not comfortable taking the baby to the NBN. The Neo rushes to the DR and finds the infant in mild respiratory distress with oxygen saturations in the mid-80s. The baby does not appear distressed, the heart rate is in the 120s, and the pulses are equal throughout. The Neo applies CPAP and asks the OB about the significant pregnancy complications. The OB states that the mother had gestational DM. The Neo then orders a CXR to evaluate heart size, shape, and lung fields, which is unremarkable. At 25 minutes of life, the infant’s oxygen saturations are above 95%, and the CPAP is removed. The infant is observed for another 10 minutes and then cleared for transport to NBN. The Neo updates the parents and documents in the chart—total time 40 minutes.

When a consult code is used, the documentation should reflect the request for a consult and the total time spent. CPT 2023 has revised the time requirements.

CPT Code	Time (minutes)
99252	35
99253	45
99254	60
99255	80

With the updated CPT, the face-to-face time with the patient does not have to be documented separately, merely the total time.

Because the resuscitation was over, neither delivery room code was appropriate.

Despite the exam and history obtained, this does not meet the requirement for H&P. Therefore; answer C cannot be used.

Scenario #2

The neonatologist on call is requested to come to the Level II nursery. A 5-day-old 33-week infant receiving low flow oxygen via NC, approximately 100 ml/kg enteral feedings, and has a PIV for TPN running at approximately 50 ml/kg. She weighs 1750 grams today. She was seen by a member of the same physician group this morning. The nurse at the bedside tells you the baby has had increasing oxygen needs and abdominal distension throughout her shift and has passed a bloody stool. On exam, the abdomen is discolored and grossly distended, and during the exam, the infant has a significant apneic episode. The neonatologist intubates the infant, stops feeds, places a Replogle, and orders an X-ray showing diffuse pneumatosis. Labs are drawn, broad-spectrum antibiotics are ordered, and the infant is transferred to the Level IV nursery across the hall, total time spent 75 minutes.

This infant was initially admitted to the Level II nursery. All admit codes can only be used once per admission, and since this infant has spent the entire admission in the intensive care unit, this transfer to critical care qualifies for a critical care admission code. The critical care codes are 24-hour global and bundled, meaning most procedures are included and cannot be billed separately. Since critical care had been provided (intubation, PPV,) this code could be used. However, the infant was transferred to Level IV and will be cared for there. Thus, the global code is more appropriate.

Scenario #3

The pediatrician on call is asked to come urgently to the Emergency Department. EMS has dropped off a newly born infant from a birthing center. The infant appears term, is pale, grunting, and is lethargic. Their heart rate is 190’s. The dad had accompanied the infant and said there was “a lot of blood” when the baby came out. The pediatrician suspects a cord accident or placental abruption. She quickly places a UVC (5 minutes), gives a bolus of NS over 10 minutes, and orders emergency blood. The respiratory distress worsens, and the pediatrician intubates the infant (5 minutes). The pediatrician calls the regional NICU (covered by a different group) for transfer. The total time spent was 80 minutes.

Procedures are not bundled with critical care time but must be subtracted from total critical care time. After subtracting procedural time, the critical care time does not exceed 74 minutes, and 99292 cannot be added as in answer A. If this infant had been admitted directly to NICU in this facility and the neonatologist and the pediatrician were in the same group, 99468 would be used, and separate codes from ED would not be entered. Since the infant is being transferred to a different facility and covered by a different group, the pediatrician can submit codes reflecting the work done in ED.

Unpredictability is the hallmark of Neonatology. When you think everything is under control, a fire breaks out somewhere, requiring your time and attention. Coding and documentation is the boring part of the job, but even firefighters have boring parts, too. I see them at the grocery store every time I go.

Let us be like firefighters: always look on the bright side and approach our work with a burning passion!