When weighing an infant is too risky, support 99478-99480 with these steps.
If you’re bundling resuscitation with initial intensive care, jumping from normal newborn codes to subsequent critical or intensive care, or omitting weight from subsequent intensive care (SIC) notes, your inpatient coding needs a checkup.
Fix 1: Watch for Rx Absent SIC Weight
A show of hands at the recent Multi-Specialty National Coding and Reimbursement Conference in Orlando revealed that the majority of coders were not seeing a weight statistic per day on subsequent intensive care charts. "Flipping back a day or days in the chart to code based on the infant’s last recorded weight is inappropriate," warned Jill M. Young, CPC, CPC-ED, CPC-IM, with Young Medical Consulting, LLC, in East Lansing, Mich.
Why: You choose subsequent intensive care (SIC) codes (99478-99480, Subsequent intensive care, per day, for the evaluation and management of the recovering … infant [present body weight … grams]) based on the infant’s present body weight, not birth weight:
• less than 1500 grams -- 99478
• 1,500-2,500 grams -- 99479
• 2,501-5,000 grams -- 99480.
"An auditor would expect to see documentation indicating the infant’s weight on that date," Young stresses.
What do you do if weighing the infant would endanger his health? "Many clinical situations could cause this to happen," Molteni says. Here’s how he says you can still properly support 99478-99480 in these cases.
Step 1: Let staff know that the note should give the reason the physician says makes it not appropriate to weigh the infant.
Step 2: "Base the weight on the last obtained" measurement, which should be the previous day’s record.
Fix 2: Go With 1 Initial CC/IC, Then Subsequent
When an inpatient normal newborn requires critical or intensive care, make sure you first use an initial:
• critical (99468, Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less)
• or intensive (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) care code.
Reason: A patient cannot go from regular first (99460, Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) or second day care (99462, Subsequent hospital care, per day, for the evaluation and management of normal newborn) to subsequent critical (99469, Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less) or intensive care (99478-99480). "The subsequent intensive care codes are always used after an-initial day of either 99468 or 99477," says Richard A. Molteni, MD, a neonatalogist at Seattle Children’s Hospital.
Work within the critical care (CC)/intensive care (IC) families. For a-newborn who becomes critically ill after receiving subsequent intensive care, "you would use subsequent 99469, not an initial code (99468)," Molteni instructs.
Fix 3: Allow 99465 With Inpatient Care
Just because a newborn requires resuscitation in the delivery room, you should not assume the patient will require critical care services. "There are some neonates who do require resuscitation (99465, Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output) including positive pressure ventilation (which might be given by bagging or even intubation), but subsequently stabilize in the resuscitation/delivery room-and do not require admission to a critical care status (99468), but rather an intensive care status (99477) or even well baby nursery (99460)," reports Steven B. Spedale, MD, FAAP, president of Infamedics and Chief of Neonatology at Woman’s Hospital in Baton Rouge, La.
Problem: Pediatric Coding Alert, Vol. 11, No 12, states, "Make sure you don’t bill 99465 (old 99440) in conjunction with 99477," based on a note following 99465 in CPT 2009. But the AMA’s instruction is a mistake.
"This was corrected in the CPT Assistant," says Gilbert I. Martin, MD, FAAP, neonatal intensive care unit (NICU) director at Citrus Valley Medical Center in West Covina, "Therefore, you can use 99465 with any of the codes including normal Cal. newborn. The latter is not a usual clinical scenario."
These 4 characteristics signal $13 screening is appropriate.
Do you circle 96110 for asking a few questions at a preventive medicine service? Your improper use of the screening code is fueling 96110-well visit bundles.
Instead: Look for these defining factors to avoid unbundling surveillance and ensure meeting 96110’s (Developmental testing; limited [e.g., Developmental Screening Test II, Early Language Milestone Screen], with interpretation and report) requirements.
Do: Include Basic Questioning in Preventive Medicine Service
The Bright Futures Guidelines recommend general developmental surveillance at all preventive medicine services except for the 9-, 18-, and 30-month encounters, which involve formal screenings. The surveillance entails the pediatrician quickly assessing how the child is progressing using questions, explains Charles A. Scott, MD, FAAP, pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey. "Surveillance does not mean extensive Denver screening."
You should consider informal questioning a part of the preventive medicine service. So you would include the surveillance in 99381-99385 ("Preventive Medicine Services, New Patient") or 99391-99395 ("Preventive Medicine Services, Established Patient").
Be careful not to unbundle the surveillance from the preventive medicine service, Scott warns. "When every preventive medicine service claim also has 96110, then there would be a problem" about appropriateness and distinctness. Overuse can fuel insurers bundling 96110 with 99381-99385 and 99391-99395.
To some extent this is already happening. "Starting in 2009, some private payers have now bundled 96110 with well visits," says Tracy Russell, CBCS, with Carroll Children’s Center in Westminster, Md.
Exceptions: Aetna, CIGNA, and Humana now pay separately for developmental screening as part of the standard benefits plan (although some individual health plan coverage may vary), according to the Connecticut American Academy of Pediatrics (CTAAP) "Check-Up: CTAAP News Brief." This amounts to approximately $13 using the 2009 Medicare Physician Fee Schedule that assigns 0.36 relative value units to 96110.
Do: Expect Standardized Tool for Codeable Screening
Do not report 96110 unless the screening uses a validated standardized instrument, says Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. Some qualifying test examples include:
• Ages and Stages Questionnaire (ASQ)
• Brigance Early Preschool
• Developmental Profile
• Early Language Milestone Scales
Do: Check If I&R Requirements Are Met
Code 96110 is for developmental testing, limited, "with interpretation and report" (I&R). Here’s what Scott says I&R means:
Interpretation: The interpretation has to follow a formal assessment like a Denver sheet. The interpretation is the assessment.
Report: The report is the documentation, such as the score or designation as "normal" or "abnormal," in the chart. You do not have to be sending the report to someone else.
The physician, however, must indicate he reviewed and discussed the screening’s results with the patient/ family member, says Tuck. A sufficient note from the doctor could state, "Developmental screening [Indicate: Normal or abnormal] reviewed and discussed."
Do: Track Payers’ Modifier Guidelines
Your payment for 96110 might hinge on using the payer’s preferred modifier method. To indicate that the preventive medicine service is significant and separate from the developmental testing, you may need to append 99381-99385 or 99391-99395 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) based on CPT guidelines. Some payers may instead require you to use modifier 59 (Distinct procedural service) on 96110 to indicate the screening is distinct from the preventive medicine service. Before using modifier 59, make sure you have written instruction from the payer. Here are two instances when 59 may be the way to go:
• CIGNA’s claim system requires manual processing for 96110 and preventive medicine service claims involving modifier 25, but will automatically process the CPT coding pair if modifier 59 is used on 96110 instead of modifier 25 on 99381-99385 or 99381-99395.
• Horizon Blue Cross Blue Shield of New Jersey requires modifier 59 for 96110 payment with a preventive medicine service.
But don’t expect your payment struggle to end with the payer-preferred modifier. If the insurer, such as United Health Care, considers the developmental testing a covered part of the preventive medicine service, as about half of the Blue Cross Blue Shield plans do, you cannot balance bill the patient for the service. Consider bulk appealing bundling policies using the American Academy of Pediatric’s supporting documentation letter available from www.aap.org/mentalhealth/cak/MH%20Payment%20Ltrs.doc.
Other policies may consider 96110 a noncovered service leaving payment to the patient’s responsibility. "Some insurers still consider 96110 a mental health code and will not pay," Russell points out.
Good idea: To make sure parents are aware that they may be responsible for payment, have them sign a private payer version of an advance beneficiary notice (ABN). Include an estimate of the charge. "Avoid surprises for your patients!" Tuck advises. Bonus: For a ready-to-go form, email the editor at email@example.com with subject line "PP ABN."