Coding Strategy

These edits took effect April 1, so start observing them yesterday.

The latest version of the Correct Coding Initiative (CCI) has an edit that family practice coders should note – especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

• 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity …)
• 99232 (… an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity …)
• 99233 (… a detailed interval history; a detailed examination; medical decision making of high complexity …).

Column 2 of these edits includes these codes:

• 99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)
• 99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)
• 99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for “normal” newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233) are for problem-oriented services, Moore says.

Since both sets of services are designated as “per day,”coders must choose between them for a given patient on a given date. “Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits,” Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.

@ Family Practice Coding Alert. Editor: Chris Boucher, CPC

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Sort your normal, sick and intensive care options.

Choosing the appropriate codes for initial newborn services can be difficult due to the large number of available codes and gray areas between the spectrum of illnesses. If you find yourself getting tripped up by the multiple categories, read on for expert tips and real-world examples that will point you in the right direction every time.

Normal Care Means No Problems

A “normal” newborn has no medical conditions or need for special care. Report the history and examination with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant).

Donelle Holle, RN, a consultant with Pedscoding.com in Indiana says this initial care includes five things:

• Maternal and/or fetal and newborn history

• Newborn physical examination

• Ordering of diagnostic tests and treatments

• Meetings with the family

• Documentation in the medical record.

Diagnosis tip: When billing with 99460, include diagnosis V30.x x (Single liveborn). “Because 99460 states ‘normal newborn,’ you cannot have any other diagnosis for that CPT code,” Holle explains.

Add-ons: Procedures such as circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes (99460-99463). Be sure to code the circumcision in addition to the newborn care. To indicate 99460-99463 is significantly identifiable from the minor E/M included in surgical codes, append 99460-99463 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Sick Newborn Needs Inpatient Codes

When the pediatrician provides E/M services for newborns who are other than normal, CPT directs you to report the codes for hospital inpatient (99221-99233) or neonatal intensive (99477-99480)  or critical care (99468-99469) services.

A baby considered a “sick” newborn might have a fever, high hemoglobin count, or MILD RESP DISTRESS. For a sick newborn, you’ll select from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient …) for the first day, based on the level of history, examination, and medical decision making.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The physician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn’s care with the appropriate choice from 99221-99223.

Intensive Care Require Extra Monitoring

Sometimes infants and neonates are not critically ill but need intensive cardiac or respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, nutritional adjustments, or laboratory and oxygen monitoring. These babies also require constant observation by the health care team under direct physician supervision.

“These infants are not critically ill but do require further monitoring or services that MAY require them to be in the neonatal intensive care unit (NICU),” Holle says.

Remember the level of care delivered — not the site of service — determines the code you choose, says Richard Tuck, MD, FAAP, a pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Intensive care codes could apply to a baby in the newborn nursery or NICU.

Example: An infant is born at 37 weeks gestation with mild tachypnea and requires 30 percent O2 by nasal cannula. The pediatrician acquires cultures and initiates IV antibiotics. Close monitoring is maintained; no additional intervention is indicated.

For the first day of this baby’s care, report 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or less, who requires intensive observation, frequent interventions, and other intensive care services). Additional days should be coded according to the infant’s status.

• “If the neonate continues to require intensive monitoring, frequent interventions, observation, or other intensive care services, use the low birth weight or recovering infant codes,” Holle says. Choose from 99478-99480 (Subsequent intensive care, per day, for the evaluation and management of the recovering infant …), based on the infant’s weight.

• If the child is still ill but no longer requires intensive or critical care services, Holle says to select from 99321-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …).

• “Sometimes a child moves from being intensively ill to being ill, to being well,” Tuck explains.  Once the child is well, turn to 99462.

What should you report if neonates meet critical care status? Subscribe to the Pediatric Coding Alert or go to www.supercoder.com for the answer.

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