Practice Management: Use new intensive care code 99477 for babies who get well fast

New neonatal intensive care code 99477 fills an important gap between critical care (99295) and regular hospital admission (99221-99223) codes.

Code 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) will typically be used for babies who need intensive care on the first day of admission, but normal levels of care by the second, according to Richard A. Molteni, MD, a neonatologist with the American Medical Association (AMA) CPT Advisory Committee.

"I suspect that we will see use of this code at birth for babies with mild respiratory distress or who are a little 'shocky,'" Molteni says. "Some of these babies may become truly critical, but the majority will be sick and then get better."

Coding for second day of care after use of 99477 would follow these guidelines:

(Note: Subsequent days with continuing intensive care services would be reported with 99298-99300 only if the baby weighed 5,000 grams or less [99300, according to CPT].)

New code better reflects level of care

Before the introduction of this code, most pediatricians used 99223 for babies requiring intensive care services, Molteni says. "They knew they were terribly underpaid for this work." Others pushed the boundaries of coding convention and reported 99295, he adds. They were well paid, but auditors noted that these babies did not meet critical care criteria for 99295. (Note: Medicare unadjusted fees are $189 for 99223 and $950 for 99295, although private payer fees vary).

The new code will get pediatricians out of this bind: no more choosing between underpayment and overpayment. Asked if payers will jump on the opportunity to scrutinize 99295 now that there is an alternative, Molteni responds, "I hope payers do push 99477 for people who are inappropriately coding this service as 99295." If private payers were to follow Medicare's fee schedule, they would pay $354.

The relative value units (RVUs) assigned to each of these codes tells a clear story about reimbursement levels. Normal newborn code 99433 is assigned 1.54, while 99233 is 4.96 and 99295 jumps to almost 25 RVUs. New code 99477 splits this difference with 9.30.

Clarifying a gray area

99477 fills a gray area between routine inpatient care and critical services, says JoAnne M. Wolf, RHIT, CPC, coding manager for Children's Physician Network, a network of clinics in the Minneapolis-St. Paul area with 250 primary care pediatric providers and more than 400 pediatric specialists. "I train people on what their options are in the hospital when a baby comes in. When it's a normal newborn, there's no problem. And when there's some problem that's not critical, it's regular inpatient care." The new code is somewhere in between regular and critical care, she says.

And there's a clear distinction between critical care and intensive care, adds Molteni, who is Physician Liaison for Strategic Planning and Business Development at Children's Hospital and Regional Medical Center in Seattle, Wash. Critical care codes require "imminent danger of death" and "organ system failure." "The frequency of lab testing, examinations, and notes can help to decide who qualifies for 99295 and who qualifies for 99477," he points out.

To justify use of 99477, however, "the documentation will likewise have to show why this is not a routine hospital code," he says. "100% of the burden of deciding whether a baby needs critical care, intensive services, or is normal falls to the physician. If the doctor says a baby is a step above the regular hospital codes and needs intensive services, that's what it is."

Coder's alert: CPT treats the intensive care codes like critical care codes, and bundles a range of services into both (see box). Molteni explains that the RVUs for 99477 take into account the bundled procedures, as well as the fact that this is a neonate and not an adult.

MS. INSINGER is an editor at the Pediatric Coder's Pink Sheet. Reprinted from the Pediatric Coder's Pink Sheet, © 2008 Decision Health. For more information on the Pediatric Coder's Pink Sheet, call 1-877-602-3835, or visit the Web site at http://www.decisionhealth.com/index2.aspx?prod_id=361&cat_it=4.