Scott D. Duncan, MD, MHA

The Kanas City Chiefs won the Super Bowl on February 11 over the San Francisco 49ers by a score of 25-22 in a thrilling overtime game. The majority of the time, each team huddled before the execution of the next play. You can imagine that both teams came prepared with a game plan, likely prepared by a number of the coaches, who conferenced before arriving in Las Vegas. So, it is with healthcare and optimal management of complex patients. 

In neonatology, we have expanded the concept of huddles. We now have daily morning huddles, evening huddles, safety huddles, labor and delivery huddles, respiratory huddles, and environmental huddles, to name a few. Underlying all these daily huddles is the delivery of optimal care to the patient and their family, where the team caring for the patient has developed an overall care plan. 

In order to establish the care plan for the complex patient, multiple providers from different service lines may meet to discuss the approach to the patient. Further, these providers may also engage the patient and family to discuss the care plan and goals for care. 

Q: An infant who suffered from NEC and now has short gut syndrome is being cared for in a surgical ICU, where the Pediatric Surgeons are the care providers. Neonatology has been consulted in the past to help formulate the plan for cyclic TPN. Neonatology last saw the patient approximately 14 days ago. The surgeons would like to have a care conference with the treatment team, including the surgeon, neonatologist, gastroenterologist, home health infusion nurses, occupational therapist, and speech therapy. The conference is to formulate a plan of care in preparation for discharge. The family will meet with the care team the following week. The conference lasts 70 minutes. The proper code for the neonatologist would be: 

1. 99233 – Subsequent hospital inpatient care, 50 minutes met or exceeded 
2. 99366 – Medical team conference with an interdisciplinary team of health professionals, face to face with the patient/family, non-physician qualified healthcare professional, 30 minutes or more 
3. 99367 – Medical team conference with an interdisciplinary team of health professionals, patient/family not present, participation by a physician, 30 minutes or more 
4. 99368 – Medical team conference with an interdisciplinary team of health professionals, patient/family not present, participation by a non-physician healthcare professional, 30 minutes or more 

Correct Answer: C – 99367 – Medical team conference with an interdisciplinary team of health professionals, patient/family not present, participation by a physician, 30 minutes or more 

Q: Following the medical team conference the previous week, the surgeons arrange a care conference with the surgeon, neonatologist, gastroenterologist, home health, including infusion nurses, occupational therapy, speech therapist, and the family. The conference will relay the care plan to the family in preparation for discharge. The conference lasts 60 minutes. No other E/M services were provided by neonatology on the day of the conference. The proper code for the neonatologist would be: 

1. 99233 – Subsequent hospital inpatient care, 50 minutes met or exceeded 
2. 99366 – Medical team conference with an interdisciplinary team of health professionals, face to face with the patient/ family, non-physician qualified healthcare professional, 30 minutes or more 
3. 99367 – Medical team conference with an interdisciplinary team of health professionals, patient/family not present, participation by a physician, 30 minutes or more 
4. 99368 – Medical team conference with an interdisciplinary team of health professionals, patient/family not present, participation by a non-physician healthcare professional, 30 minutes or more 

Correct Answer: A – 99233 – Subsequent hospital inpatient care, 50 minutes met or exceeded 

Most conversations with families occur during or after rounds, via phone, or at the bedside. Those conversations are bundled within the daily global critical care, intensive care, and E/M services. The encounter is billable only when medical team conferences occur when providing consultative services. 

Medical team conferences require a minimum of three qualified healthcare providers (QHP) from different specialties who provide direct care to the patient. These QHPs, like the coaching staff, are tasked with creating and implementing the care plan. In order to code for these services, the QHP must have provided direct services within the last 60 days. 

These codes require a minimum of 30 minutes of conference time, exclusive to record-keeping or generation of records, and limited to the time the QHP communicates to other healthcare team members. Documentation should include the provider’s contribution to the conference, treatment recommendation, and time. These codes do not apply when the conference is a scheduled facility or organizational service, such as weekly discharge planning rounds. 

The second continuing scenario presents a medical team conference with a face-to-face encounter with the family. Given that the consulting neonatologist provided no other E/M services on the encounter date, they could bill for an E/M service based on time. As a previous consultation was performed, the neonatologist should code for subsequent hospital inpatient care. 

Despite a declining national birth rate, neonatology discharges continue to rise, and the complexity of our patients continues to grow. Not all payors may recognize medical team consultation codes, and the physician codes do not place a high RVU value on this service. Yet, creating and executing a comprehensive care plan is essential to the health of our NICU graduates.