Neonatal Critical Care Coding: Guidelines for Accurate Billing and Reimbursement

I. Understanding Neonatal Coding and its Financial Impact

For neonatal healthcare providers, accurate Current Procedural Terminology (CPT®) coding is crucial for appropriate professional reimbursement. The level of care coded in settings like the Neonatal Intensive Care Unit (NICU), newborn nurseries, and other neonatal care areas directly impacts revenue. There are four primary levels of Evaluation and Management (E&M) codes applicable to neonates: critical care, intensive care, routine hospital care, and normal newborn care. These categories are associated with significantly different work Relative Value Units (wRVUs), highlighting the financial implications of coding choices. This article offers an overview of the core characteristics of each of these care levels, with a particular focus on differentiating between critical and intensive care coding guidelines. Given the ever-evolving nature of coding and billing, and the potential for varied interpretations, healthcare professionals are urged to consult the most current CPT® coding publications to make informed decisions regarding the optimal codes for their neonatal patients.

II. The Foundation of Neonatal Coding: CPT® and ICD-10

A strong understanding of coding is fundamental to the financial health of any neonatology practice. Each group should prioritize coding oversight, potentially assigning a dedicated expert to supervise coding and billing processes. Establishing a positive working relationship with the business office handling these functions is essential for ensuring accurate code utilization, which is vital for the practice’s financial stability. A recent national survey underscored the knowledge gaps in neonatal coding practices, highlighting the need for improved training and expertise [1]. Notably, self-coding and participation in coding education, such as courses or webinars, were linked to greater coding accuracy.

The CPT® system [2], developed by the American Medical Association (AMA), serves as the industry standard for describing medical, surgical, and diagnostic services. Revised annually, CPT® uses standardized terminology to communicate the services provided by clinicians to insurance payers [3, 4]. Each CPT® code is assigned a work relative value unit (wRVU), as shown in Table 1 [2]. Neonatal coding [5, 6] primarily utilizes global daily codes. These bundled codes encompass common procedures and are typically used once per 24-hour period, based on the patient’s age and the level of care provided [2, 3]. Understanding the nuances of these code definitions is crucial, especially when distinguishing between critical and intensive care service codes, a differentiation with significant financial implications for neonatologists and their business offices.

Complementing CPT® codes are the International Classification of Diseases (ICD) codes. The ICD system is designed to ensure global consistency in the collection, processing, and reporting of mortality and morbidity statistics [7]. The tenth revision, ICD-10, has been used in the US since October 1, 2015. ICD-10 codes are diagnostic codes that must substantiate the CPT® codes submitted for reimbursement. Any mismatch between the diagnosis and the billing code will lead to claim denials from insurance carriers. For instance, within ICD-10, codes P00-P96 are dedicated to conditions originating in the perinatal period. Using precise codes, such as P22.0 for respiratory distress syndrome (RDS) of newborn instead of a general code for respiratory distress (P22), is vital for diagnostic accuracy and appropriate reimbursement.

III. Decoding Global Daily Codes in Neonatal Care

Global, bundled daily codes are the cornerstone of neonatal care billing, categorized by complexity (Table 1). In descending order of service intensity, these codes include critical care, intensive care, hospital care, and normal newborn care.

Critical Care: Defining Life-Threatening Conditions

Critical care, as defined by CPT®, is for patients with a “critical illness or injury that acutely impairs one or more vital organs and has a high probability of imminent or life-threatening deterioration.” Critical care is the direct medical care delivered by a physician or qualified healthcare professional (QHP) to a critically ill or injured patient. Critical care codes are appropriate when both of these criteria are met: (a) the patient has a critical illness or injury as defined by CPT®, and (b) the treatment involves “high-complexity decision making to assess, manipulate, and support vital organ system function(s) to treat single or multiple organ system failure and/or prevent further life-threatening deterioration of patient’s condition.” The location of care is not the determining factor for critical care coding; the key is the service provided by a physician or QHP. Many procedures, such as umbilical catheterization, intubation, and surfactant administration, are bundled into daily critical care codes. Procedures that can be billed separately from daily critical care codes are listed in Table 2.

Examples of conditions and interventions that typically warrant critical care coding include:

• Respiratory failure requiring invasive or noninvasive ventilation or nasal CPAP.
• Hypotension, shock, or cardiac failure needing inotropic or vasopressor support.
• Congenital heart disease requiring prostaglandin E1 infusion.
• RDS requiring surfactant. (Note: ICD-10 inherently links respiratory failure to RDS.)
• Hypoxemic respiratory failure, pulmonary hypertension, or right ventricular failure needing inhaled nitric oxide (iNO).
• Severe hyperbilirubinemia treated with double volume exchange transfusion.
• Symptomatic polycythemia requiring partial exchange transfusion.
• Acute tension pneumothorax, pneumopericardium, or pleural/pericardial effusion causing life-threatening deterioration requiring chest tube or pericardial drain placement. (Note: Surgical protocol chest tube or drain placement alone doesn’t justify critical care.)
• Severe bradycardia or cardiac arrest requiring CPR (including chest compressions).
• Renal failure or acute tubular necrosis needing therapeutic intervention.
• Necrotizing enterocolitis (Bell’s stage II+) with orogastric suction and nil per os.
• Moderate to severe hypoxic-ischemic encephalopathy (HIE) with therapeutic hypothermia.
• Status epilepticus or intractable seizures receiving antiepileptic therapy.
• Unstable congestive heart failure requiring frequent medication and respiratory support adjustments.
• Post-operative management after general anesthesia if respiratory support and cardiovascular/pain medication adjustments are needed. (Appropriate modifiers are needed if the surgical code includes post-operative care; consult coding experts for optimal coding and modifier use in these cases.)

Effective documentation to support critical care coding should use terms like “failure,” “imminent,” and “life-threatening deterioration” to describe the patient’s condition. While CPT® does not explicitly define “imminent” and “life-threatening,” established organ system failure definitions, such as respiratory failure (PaO2, SpO2, or PCO2 outside normal ranges requiring intervention), should be used.

Intensive Care: For High-Acuity, Non-Critical Neonates

Intensive care is designated for neonates and infants who, while not meeting the criteria for critical illness, still require intensive observation, frequent interventions, and intensive services. This includes continuous cardiorespiratory monitoring, frequent vital sign monitoring, temperature maintenance, enteral/parenteral nutrition adjustments, laboratory and oxygen monitoring, and constant healthcare team observation under physician or QHP supervision. These codes are commonly used for recovering low birth weight infants (“growing preemies”) needing ongoing high-level care for issues like temperature instability, apnea/bradycardia monitoring, low-flow nasal cannula support, and nutritional support. If this level of intensive monitoring and care is not necessary, subsequent hospital care (99231–99233) or normal newborn care (99462) codes are more appropriate.

Distinguishing between critical and intensive care can be challenging and open to interpretation. Thorough documentation justifying the chosen level of care is crucial for insurance claim approval.

IV. Documentation: The Key to Coding Accuracy

Detailed documentation within the electronic medical record (EMR) is essential to justify both critical and intensive care coding. Documentation serves a dual purpose: communicating the patient’s medical status and detailing the care provided. Beyond standard documentation elements like history and physical exam reviews, critical care codes require specific information. The note must clearly state the patient’s critical illness with organ failure, comprehensively describe all care provided, and demonstrate the high-complexity medical decision-making (MDM) involved in assessing and supporting organ failure or preventing life-threatening deterioration. Intensive care documentation should similarly include a description of the patient’s condition, the need for continuous or frequent vital sign monitoring or therapy adjustments, and constant healthcare team observation. For both critical and intensive care, the clinician must document their direct supervision of all care aspects. Table 3 provides suggested documentation phrases for critical and intensive care.

Table 3. Suggested documentation to justify critical and intensive care.

CRITICAL: This patient is experiencing vital organ impairment requiring support and interventions as delineated in the above problem list. Medical management including frequent assessments of patient status, medical decision making, and intervention adjustments of high complexity is required to prevent life-threatening deterioration in the patient’s condition.
INTENSIVE/WEIGHT-BASED: This patient is under constant supervision by the health care team and is requiring intensive cardiac and respiratory monitoring, including frequent or continuous vital sign monitoring, maintenance of neutral thermal environment and/or nutritional management. Current status and treatment are delineated in the above problem list.

Hospital care codes (99221–99223 for initial and 99231–99233 for subsequent care, Table 1) are used for ill newborns who don’t require intensive or critical care but still need a higher level of physician care, nursing observation, or physiologic monitoring. These are also daily codes, with the specific code selected based on MDM complexity and/or time spent.

Normal newborn care codes (Table 1) apply to infants from birth through 28 days who have undergone normal transition after birth, regardless of delivery room interventions [2, 3]. Codes exist for initial care, subsequent care, and same-day admission and discharge.

V. Hourly Critical Care Coding: Specific Use Cases

Hourly critical care codes (99291 for the first 30–74 minutes, 99292 for each additional 30 minutes) are used in specific situations. Critical care time includes face-to-face time with the patient and time directly related to patient care, such as reviewing tests, family discussions, staff consultations, and EMR documentation. Certain bedside procedures bundled with global critical care codes are not bundled with hourly codes. Time spent on separately billable procedures cannot be included in hourly critical care time. Hourly codes can be used instead of or alongside daily global codes in the following scenarios:

• Concurrent critical care by a second specialist from a different specialty providing unique services (e.g., cardiologist, pulmonologist, nephrologist, or pediatric intensivist). For example, a neonate in the PICU or cardiac ICU might need a neonatologist for specialized critical care, like managing a high-frequency jet ventilator.
• Transfer of care, such as from the NICU to the cardiac ICU post-cardiac surgery. The NICU neonatologist would use hourly critical care codes, while the cardiac intensivist would use daily global critical care codes.
• For hourly critical care coding, the second specialist must provide at least 30 cumulative minutes of critical care (continuous or intermittent) per day in the unit. Time from physicians or QHPs of the same specialty and medical group can be combined.
• Critical care services provided in preparation for transferring a critically ill neonate to a different neonatology group and hospital system.

VI. Clarifications on Critical and Intensive Care Coding Guidelines

Telemedicine and Provider Presence

Traditionally, daily global critical and intensive care required direct, in-person patient care. However, under the ongoing public health emergency, the Centers for Medicare and Medicaid Services (CMS) have temporarily allowed these codes to be used for telemedicine services (this exception is currently set to expire on December 31, 2023; refer to the CMS website for updates beyond this date: https://www.cms.gov/medicare/medicare-general-information/telehealth/telehealth-codes).

In-House Physician Requirement

Continuous 24/7 in-house physician presence is not mandated for daily global critical and intensive care codes. However, the wRVUs for these codes are based on the assumption that the provider is physically present in the unit, actively providing or supervising care for a significant portion of the service day. Medically appropriate examination, assessment, and active participation must be documented in the EMR to justify critical or intensive care coding.

Neonatal vs. Pediatric Critical Care Codes

While subsequent critical care codes have the same wRVU for both neonates and pediatrics, initial neonatal critical care codes (99468) have a higher wRVU (18.46) than initial pediatric codes (99471) (15.98, Table 1). Neonatal codes are used until 28 postnatal days (birth day is day 0), and pediatric codes start on the 29th postnatal day. For example, an infant born on January 1, 2023, uses neonatal codes until January 29, 2023, and pediatric codes from January 30, 2023 [3].

Initial neonatal (99468) and pediatric (99471) codes can be used only once per hospital stay but are not admission codes. For instance, an infant admitted for intensive care on postnatal days 0–2 for hypoglycemia, who then develops sepsis and requires intubation and inotropic support on day 3, can be billed with an initial critical care code (99468) on day 3.

Initial neonatal intensive care code (99477) is age-based and applicable only to neonates 28 days or younger, regardless of weight. For infants 29 days or older admitted for intensive care, the initial day code should be 99223 (if complex MDM is involved). Conversely, subsequent intensive care codes (99478-80) are weight-based and can be used beyond the neonatal period for infants weighing ≤ 5000 grams who require intensive care.

Subsequent intensive care codes (99478-80) are weight-dependent. If a patient’s weight changes and crosses a weight threshold, the appropriate code for their current weight should be used. For example, an infant admitted on Monday at 1500g requiring intensive care (code 99477), weighing 1500g on Tuesday and 1499g on Wednesday, would be coded 99479 on Tuesday and 99478 on Wednesday.

Subsequent Intensive Care for Infants >5000g

No specific subsequent intensive care codes exist for infants exceeding 5000g. In these cases, subsequent hospital care codes are recommended. Notably, the wRVU for subsequent intensive care for 2501–5000g infants (99480) is similar to the high-complexity hospital care code (99233) (2.40 wRVUs, Table 1). Initial intensive care (99477) and critical care codes (99468 and 99469) have no weight limits and can be used for neonates over 5000g.

Discharge codes (99238 for ≤30 minutes and 99239 for >30 minutes) are time-based and are the same regardless of the level of care provided during the stay. No other daily bundled code can be billed on the discharge day. Discharge codes cover time spent on discharge examination, parent/guardian discussions, discharge planning, communication with follow-up providers, prescriptions, referrals, and discharge records. This time can be cumulative throughout the discharge day. Documenting specific time spent (e.g., 45 minutes) is preferable to simply stating “>30 minutes.” These codes also apply on the day of death.

Transfer of Care: Coding Guidelines

When a patient is transferred within the same facility to a different location but remains under the care of the same physician group and subspecialty, a single daily global care code applies. The same principle applies to transfers to a different facility if the physician group remains the same. For transfers involving different physician/QHP groups, consider these guidelines:

1. Acute Transfer to Higher Level of Care: If a critically ill patient is transferred to another facility and care is taken over by a different medical group, the transferring physician uses hourly critical care codes (99291–99292), and the accepting physician can use a daily global critical care code (99468 or 99471). For non-critical transfers to a tertiary facility, the transferring physician uses a hospital care code (99231–99233). If the accepting physician initiates critical care upon arrival, they can bill for critical care.
2. Back-Transfer to Lower Level of Care: When a patient receiving intensive care is transferred back to a community hospital, the transferring physician at the tertiary center uses a routine care code (99231–99233). The receiving physician at the community hospital bills a daily global intensive care code (99478–99480) or hospital care code (99231–99233). If the patient is still critical during back-transfer, the transferring physician uses hourly critical care codes, and the accepting physician uses a global critical care admit code.
3. Note: Some payers may deny daily global codes billed by two different physician groups on the same day.

Principles of Coding for Back-Transfers: The transferring provider typically does not use daily critical or intensive care codes (except in one instance noted below). The receiving provider typically uses daily codes.

1. Critical Care: Upon improvement and transfer to a lower care level within the same facility to a different group, the transferring provider does not report a daily critical care service. They report subsequent hospital inpatient/observation care (99231–99233) or time-based critical care (99291–99292), as appropriate. The receiving provider reports subsequent daily critical care (99469 or 99472), intensive care (99478–99480), or hospital care (99231–99233), as appropriate.
2. Intensive or Routine Hospital Care: When a neonate improves after the initial day and no longer needs intensive care and is transferred to a lower level of care, the transferring provider does not bill a daily intensive care service. They report subsequent hospital inpatient/observation care (99231–99233) or normal newborn care (99460, 99462), as appropriate. Exception: If transfer to a lower level occurs on the same day as initial intensive care services were provided by the transferring individual, 99477 may be reported. The receiving provider bills a global intensive care code (99478–99480) or hospital care code (99231–99233) as appropriate.
3. Discharge codes (99238–99239) are not used for transfers as the baby is not going home.

Car seat testing codes (94780 and +94781) can be used with hospital care (99231–99233), normal newborn care (99460–99463), or discharge codes (99238–99239), but not with subsequent intensive care codes (99478–99480).

VII. Controversial Coding Areas in Neonatal Care

High Flow Nasal Cannula (HFNC)

The use of heated, humidified high-flow nasal cannula is common in the NICU. Coding (critical vs. intensive) depends on illness severity and service intensity. If HFNC is used for critical conditions like respiratory failure due to RDS, BPD, or frequent apnea, and withdrawal would likely cause life-threatening deterioration, critical care coding is justifiable. EMR documentation should reflect this rationale. If this justification is not documented, intensive care or hospital care codes are more appropriate.

Unstable apnea and bradycardia of prematurity (multiple spells/24 hours requiring significant stimulation or mask ventilation) may warrant critical care. If such spells don’t require active physician/QHP intervention, intensive care codes may be considered.

Extreme Prematurity

Extremely premature infants (<28 weeks gestation) often require intensive resources. While extreme prematurity alone doesn’t automatically qualify for critical care, these infants often have critical conditions (e.g., severe RDS, sepsis) that do justify critical care coding based on the guidelines discussed.

Hypoglycemia

Late preterm and term infants transferred to the NICU for hypoglycemia management may qualify for intensive care codes if they require continuous IV glucose, frequent monitoring and adjustments, or central line placement for high glucose concentrations. Persistent hypoglycemia needing high glucose infusion rates and additional therapies like diazoxide or glucagon may justify critical care. Stable glucose levels without frequent monitoring may be better suited for hospital care codes.

VIII. Conclusion: Navigating Neonatal Critical Care Coding

A fundamental understanding of neonatal coding, particularly the distinction between critical and intensive care, is essential for neonatologists. The wRVU differences between these codes are significant, making accurate coding crucial for appropriate reimbursement. Justifying the chosen code necessitates thorough documentation of physician involvement, patient illness severity, and services provided. Future healthcare reimbursement models, focusing on value-based care, outcomes, and patient satisfaction, will likely add further complexity to physician compensation and coding practices [8, 9, 10].

Disclaimer: CPT® code descriptions and interpretations are subject to change. Always refer to the most current guidelines and recommendations. This article reflects 2023 guidelines. Neonatal providers should base coding decisions on individual patient illness and care provided, making informed choices about appropriate service codes. Payor interpretations of CPT® codes can vary, so consultation with billers, coders, and insurance representatives may be beneficial.

References

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