2008 Coding Questions and Answers

Transcription

1 2008 Coding Questions and Answers 1. An infant is born at 29 wks gestation and has RDS. His birthweight is 1200 gms. He is admitted to the NICU. It is evident that he has severe RDS and a decision is made to intubate and give a surfactant. Answer A The proper code(s): a b , c , 31520, represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) Since the intubation and Surfactant was given in the NICU, these procedures are bundled and can not be coded separately. 2. The above infant (An infant is born at 29 wks gestation and has RDS. His birthweight is 1200 gms. He is admitted to the NICU. It is evident that he has severe RDS and a decision is made to intubate and give a surfactant.) is now in your NICU and is extubated at 24 hours of age and placed on NCPAP. He continues to receive IV fluids and is started on trophic feedings. Answer The proper code for the 2 nd day of life: a b c represents a subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate 28 days or less. A critically ill neonate will require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations throughout a 24-hour period, and constant observation by the health care team under direct physician supervision. (CPT 2009, page 21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) NCPAP can be considered a criteria for a critical baby if documentation supports the critical nature of the illness. Remember that the expression a high probably imminent or life threatening deterioration of the patient s condition should be part of the physician s note. 1

2 3. On day 3 of life, the infant (An infant is born at 29 wks gestation and has RDS. His birthweight is 1200 gms. He is admitted to the NICU. It is evident that he has severe RDS and a decision is made to intubate and give a surfactant) is now in a hood receiving 30% oxygen. He continues on IV fluids and advancing feeding. He is also started on caffeine for apnea. Answer A The proper code is: a b c represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight less than 1500 g). Infants with present boy weight less than 1500 grams who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. This is a global code and all procedures are included in the code and are not reported separately (CPT 2008, page 22; CPT Assistant 11/05:10; CPT Changes: An Insider s View 2003; Coding for Pediatrics 2008, page 100, 103, 104). This infant satisfies all the criteria for a weight-based NICU intensive care code (<1500 grams) week 1950 g preterm neonate born by vaginal delivery was hypotonic in delivery room. The baby was admitted to the NICU for a Sepsis workup. The infant was not in oxygen, was normotensive and a peripheral IV was started by the nurse. The baby was started on antibiotics. Feedings started at the end of the day. The baby was on continual monitoring. Answer C The proper code is: a b c Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). This baby satisfies all of the criteria for an intensive not critical admission to the NICU. 2

3 5. Same baby as above (34 week 1950 g preterm neonate born by vaginal delivery was hypotonic in delivery room. The baby was admitted to the NICU for a Sepsis workup. The infant was not in oxygen, was normotensive and a peripheral IV was started by the nurse. The baby was started on antibiotics. Feedings started at the end of the day. The baby was on continual monitoring.) The baby remained on antibiotics, DOL 2 6, feedings were improving but the baby was not gaining weight adequately. In addition, the baby was mildly jaundiced with a total bilirubin of 12 on day six. Answer B The proper code for day of life 2-6: a b c represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22; CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ). This baby satisfies the criteria for a weight-based code, ( grams) 6. A 36 week (2300 gram) infant is transferred back to the referral hospital after 45 days stay in the NICU. The child is on nasal cannula oxygen 0.75 lpm, NG/PO feeding and caffeine for apnea. A large volume of records accompany the infant including chest x-rays. The admitting neonatologist reviews all the records and then does a comprehensive physical exam and medical decision making of moderate complexity. Total time spent on admitting this child was 2 hours. The neonatologists in each hospital are in different groups. Answer A The proper code(s) for the neonatologist in the referral hospital is: a b c , 99356, represents the first hospital inpatient encounter with the patient by the admitting physician. It is an initial hospital care, per day, for the evaluation and management of a patient. The requirements include documentation of a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Each component, history, physical examination and medical decision making must reach the highest level of the E/M service code. (CPT 2008, page 13; CPT Assistant Aug 04:11; Coding for Pediatrics 2008, page 94; 3

4 99477 Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). At first glance a code seems appropriate as the baby satisfies the criteria for an intensive care admission. However, the infant is more than 28 days of age and the code is restricted to babies 28 days or less. Therefore the code reflecting a high complexity illness is chosen. 7. A 36 week (2300 gram) infant is transferred back to the referral hospital after 25 days stay in the NICU. The child is on nasal cannula oxygen 0.75 lpm, NG/PO feeding and caffeine for apnea. A large volume of records accompany the infant including chest x-rays. The admitting neonatologist reviews all the records and then does a comprehensive physical exam and medical decision making of moderate complexity. Total time spent on admitting this child was 2 hours. The neonatologists in each hospital are in different groups. Answer B The proper code(s) for the neonatologist in the referral hospital is: a b c , 99356, represents the first hospital inpatient encounter with the patient by the admitting physician. It is an initial hospital care, per day, for the evaluation and management of a patient. The requirements include documentation of a comprehensive history, a comprehensive examination, and medical decision making of high complexity. Each component, history, physical examination and medical decision making must reach the highest level of the E/M service code. (CPT 2008, page 13; CPT Assistant Aug 04:11; Coding for Pediatrics 2008, page 94; Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). This example reflects a intensive not critical baby of less than 28 days of age and therefore the code is correct. 4

5 8. A 10 week old now 1600 grams, former 24 week infant requires laser surgery for ROP. The baby is on nasal cannula oxygen.5lpm 30 %. The ophthalmologist requests that you provide the sedation for the infant. You give the infant Ketamine and Versed and monitor the infant s vital signs during the 45 minute procedure. A repeat dose of Ketamine is needed. You continue to monitor the infant for 15 minutes after the procedure is completed and document all of your interactions in the medical record. Answer C The proper codes are: a , 99143, x 2 b , 99149, x 2 c , 99148, x represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22;CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ) Moderate sedation services provided by the same physician performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient s level of consciousness and physiological status; younger than 5 years of age. CPT 2008, page 435. Coding for Pediatrics 2008, page each additional 15 minutes intra-service time (list separately in addition to code for primary service). Use code in conjunction with codes and CPT 2008, page 435. Coding for Pediatrics 2008, page Moderate sedeation services provided by a physician other than the health care professional performing the diagnostic or therapeutic service that the sedation supports; younger than 5 years of age, first 30 minutes intra-service time. CPT 2008, page 435. Coding for Pediatrics 2008, page age 5 years or older, first 30 minutes intra-service time. CPT 2008, page 435. Coding for Pediatrics 2008, page each additional 15 minutes intra-service time (list separately in addition to code for primary service.) Use code in conjunction with codes and CPT 2008, page 435 Coding for Pediatrics 2008, page 121 The code reflects an intensive care weight-based code of an infant grams. The moderate sedation code is used for the neonatologist is providing the sedation for the ophthalmologist. This code is utilized for a child under 5 years of age and reflects the first 30 minutes of moderate sedation is utilized for each additional 15 minutes in a patient under 5 years of age. 5

6 9. Baby girl Laurel is born at 33 weeks weighing 1550 grams and has mild respiratory distress. Dr. Hardy evaluates the baby. The baby is requiring low flow nasal cannula at 30% oxygen. She is placed on a cardiorespiratory monitor and continuous pulse oximetry, capillary blood gases, chest x-ray, CBC and blood cultures are done. Antibiotics are started, as well as, intravenous fluids. The first blood sugar is low and Dr. Hardy orders a bolus of IV dextrose to be given. Dr. Hardy re-evaluates her four hours after admission and she has stabilized on 25% oxygen after transiently needing 45%. Her blood sugar is also stabilized and Dr. Hardy orders trophic feeds to be given. Answer - C The proper code for the 1 st day is: a b c Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). The baby does not satisfy the criteria of critical and therefore the intensive non-critical code is utilized. 10. On the second day of life baby girl Laurel was weaned off oxygen but is having occasional apnea episodes. Dr. Hardy orders caffeine to be started. The pulse oximeters and monitors are continued. Parenteral nutrition is started and trophic feeds are continued. Her weight is now 1495 grams. Blood cultures are negative but antibiotics are continued. Answer - B The proper code for the 2 nd day is: a b c represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight less than 1500 g). Infants with present boy weight less than 1500 grams who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. This is a global code and all procedures are included in the code and are not reported separately. (CPT 2008, page 22; CPT Assistant 11/05:10; CPT Changes: An Insider s View 2003; Coding for Pediatrics 2008, page 100, 103, 104). This baby satisfies the criteria of a weight based intensive care code for an infant <1500 grams (99298) 6

7 11. A neonatologist is ask to consult on a 2100 gram infant with mild respiratory distress at hospital A. He spends 40 minutes with the consult and speaks with the pediatrician. The pediatrician remains the primary physician until 12 hours later when the baby deteriorates and is intubated and is transferred to hospital B for a higher level of care. The neonatologists taking care of the baby at Hospital A and Hospital B are in the same group. Answer B The proper code(s) is: a , b , c , represents an inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history, an expanded problem focused examination; and straightforward medical decision making. In general, an inpatient consultation code is used only once by the reporting physician for an individual hospital patient for a particular episode of care. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient s hospital floor or unit. Both the requesting and consulting physician must document the request in the medical record. CPT 2008, page 16, CPT Assistant Sep 02:11; CPT Changes: An Insider s View 2007, Coding for Pediatrics 2008, page 86) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code. (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96, 97) -25 modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157). The reason that a consult code (99252) can be used initially is due to the fact that the pediatrician remains the primary care physician, and the neonatololgist is the consultant. All of the documentation rules must be included if the consultation code is utilized. 12. A neonatologist is ask to consult on a 2100 gram infant with mild respiratory distress at hospital A. He spends 40 minutes with the consult and speaks with the pediatrician. The pediatrician transfers care to the neonatologist. Twelve hours later the baby deteriorates and is intubated and is transferred to hospital B for a higher level of care. The neonatologists taking care of the baby at Hospital A and Hospital B are in the same group. The proper code(s) is: a , b c ,

8 Answer B represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code. (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96, 97) A consult code (99252) is not used in this example since the pediatrician transferred care to the neonatologist. Although the intubation occurred at Hospital A it is bundled under the global code Since the neonatologists taking care of the baby at Hospital A and Hospital B are in the same group only one code can be placed. 13. A 2100 gram infant is admitted to hospital A for mild respiratory distress and the need for 40% hood oxygen and frequent vital signs. Twelve hours later the baby deteriorates, is intubated and is transferred to hospital B for a higher level of care. The neonatologist taking care of the baby at Hospital A and Hospital B are in different groups. Answer A The proper code(s) is: a , (for neo A), 99295(for neo B) b , 99291, (for neo A), (for neo B) c (for neo A), (for neo B) Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ) Critical Care, evaluation and management of the critically ill or critically injured patient; first minutes. CPT 2008, page 20. CPT Assistant Dec 06: represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code. (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96, 97) 8

9 Neonatologist A admits this intensive non-critical baby to Hospital A and uses a code. When the baby deteriorated and became critical the code (first minutes is used). Although intubation is not bundled under it is bundled under and therefore a separate code for intubation (31500) was not used. Since the neonatologists are in different groups and use separate identification numbers two separate codes can be used. 14. The baby in previous example (2100 gram infant who was critical for several days) is now seven days of age and weighs 2130 grams. He is transferred back from hospital B to hospital A. The neonatologist did not supervise or go on the transfer. The baby requires continuous monitoring and there are frequent feeding adjustments. The physicians at hospital B and hospital A are in the same group. The proper code(s) is: Answer A a b , c , represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22;CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ). Although this infant is transferred from Hospital B to Hospital A, a new admission code is not used since the neonatologists are in the same group. Therefore a follow-up, intensive care weight based code (99299) is used. If the neonatologist at Hospital B supervises or goes on the transfer a code (supervision) and code (transport) can be added. 15. The baby in previous example (2100 gram infant who was critical for several days) is now seven days of age and weighs 2130 grams. He is transferred back from hospital B to hospital A. The neonatologist did not supervise or go on the transfer. The baby requires continuous monitoring and there are frequent feeding adjustments. The physicians at hospital B and hospital A are in different groups. Answer B The proper code(s) is: a b , c ,

10 99299 represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22;CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ) Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). This infant is transferred from Hospital B to Hospital A, and a new admission code can be used since the neonatologists are in different groups. The code is used by the neonatololgist at Hospital B, and the is used by the neonatologist at Hospital A. If the neonatologist at Hospital B supervises or goes on the transfer a code (supervision) and code (transport) can be added. 16. A 2300 gram male infant is now four weeks of age and is getting ready for discharge. The neonatologist asks for a multidisciplinary conference. The conference lasts for 40 minutes and the parents are not present. Answer - C The proper code(s): a , b , c , represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22; CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ). 10

11 99367 Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more; participation by physician. CPT 2008, page 30. CPT Changes: An Insider s View Coding for Pediatrics 2008, pages 72, modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157). The weight based intensive care code reflects the code for the day in question. The team conference codes ( ) are not bundled in the intensive care weight based code. The team conference codes and are deleted in Three new team conference codes were established to differentiate the provider and to distinguish face-toface and non face-to-face team conference services. Medical team conferences include face-to-face participation by a minimum of 3 qualified health care professionals from different specialties or disciplines (each of whom provide direct care to the patient), with or without the presence of the patient, family member(s),community agencies, surrogate decision-maker(s) (eg, legal guardian), and/or caregiver(s). The participants are actively involved in the development, revision, coordination and implementation of health care services needed by the patient. These services may only be reported when the physician or other qualified health care professional has performed faceto-face evaluations and/or treatments that are separate from any team conference within the previous 60 days. Only one individual from the same specialty may report codes for the same encounter. Reporting participants shall document their participation in the team conference as well as their contributed information and subsequent treatment recommendations. The team conference starts at the beginning of the review of an individual patient and ends at the conclusion of the review. Time related to record keeping and report generation is not reported. Regularly discharged planning rounds or conferences are not reported with these codes. These conferences are specially planned to discuss the coordination of care for children and families who are cared for in the NICU where a number of disciplines must participate to develop a plan of care. The services should note be reported with t team conference if part of a facility or organizational service that is provided under contract by an organization or facility provider. When a physician provides face-to-face service at a team conference with the parents present, a E/M code is used. Team conferences of less than 30 minutes are not reported. Medical record documentation must support the participation of the physician or other qualified health care professional and the time spent from the beginning of the review of an individual patient until the conclusion of the review. A -25 modifier should be appended to the code when it is reported on the same day as E/M service to signify that a significant, separately identifiable service was provided. Medical record documentation must include the date of the conference, time spent in conference, attendees, and the issues discussed. 11

12 17. A 2300 gram male infant is now four weeks of age and is getting ready for discharge. The neonatologist asks for a multidisciplinary conference The conference lasts for 40 minutes and the parents are present. Answer C The proper code(s) is: a , b , c , represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22; CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ) represents a subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components; an expanded problem focused interval history; an expanded problem focused examination; medial decision making of moderate complexity. (CPT 2008, page 13, CPT Assistant March 07, Coding for Pediatrics 2008, page 95). -25 modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157). The weight based intensive care code reflects the code for the day in question. The team conference codes ( ) are not bundled in the intensive care weight based code. The team conference codes and are deleted in Three new team conference codes were established to differentiate the provider and to distinguish face-to-face and non face-to-face team conference services. Medical team conferences include face-to-face participation by a minimum of 3 qualified health care professionals from different specialties or disciplines (each of whom provide direct care to the patient), with or without the presence of the patient, family member(s), community agencies, surrogate decision-maker(s) (eg, legal guardian), and/or caregiver(s). The participants are actively involved in the development, revision, coordination and implementation of health care services needed by the patient. These services may only be reported when the physician or other qualified health care professional has performed face-to-face evaluations and/or treatments that are separate from any team conference within the previous 60 days. Only one individual from the same specialty may report codes for the same encounter. Reporting participants shall document their participation in the team conference as well as their contributed information and 12

13 subsequent treatment recommendations. The team conference starts at the beginning of the review of an individual patient and ends at the conclusion of the review. Time related to record keeping and report generation is not reported. Regularly discharged planning rounds or conferences are not reported with these codes. These conferences are specially planned to discuss the coordination of care for children and families who are cared for in the NICU where a number of disciplines must participate to develop a plan of care. The services should not be reported with the team conference if part of a facility or organizational service that is provided under contract by an organization or facility provider. When a physician provides face-to-face service at a team conference with the parents present, a E/M code is used. Team conferences of less than 30 minutes are not reported. Medical record documentation must support the participation of the physician or other qualified health care professional and the time spent from the beginning of the review of an individual patient until the conclusion of the review. A -25 modifier should be appended to the code when it is reported on the same day as E/M service to signify that a significant, separately identifiable service was provided. Medical record documentation must include the date of the conference, time spent in conference, attendees, and the issues discussed. 18. You are asked to attend a c-section of a 3600 gram infant. You arrive four minutes after delivery, the one minute Apgar score is 8 and you briefly examine the infant, discuss newborn care with the obstetrician and parents and document your presence. The baby is then sent to the well baby nursery. Answer B The proper code is: a b c. no charge represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91). Although the physician arrives after the actual delivery the baby is examined and the physician then orders the infant to be sent to the well baby nursery. The work provided satisfies the criteria necessary for (a cursory visual inspection and discussion of care of the newborn with the delivering physician and parents). It is important to remember that medical record documentation must include the request for attendance at delivery and substantiate the services performed. If there is no documentation by the delivering physician in the maternal medical record, the verbal request and the reason for the request should be documented attendance note. This code should not be reported without a specific request for attendance. If hospital policy requires physician attendance at a specific type of delivery (elective repeat cesarean section), attendance at delivery is not reported. 13

14 19. You are asked to attend a c-section of a 3600 gram infant. You arrive six minutes after delivery, the Apgar scores are 8, 9. The baby has already been wrapped in a blanket and you instruct the nurse to send the baby to the well baby nursery. Answer C The proper code is: a b c. no charge (code) The physician arrives after the delivery and his/her physical presence is not necessary since the infant has already been cared for by the nurse. The physician does not satisfy the criteria inherent in the definition of (Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate and discussion with the obstetrician and parents). There is no code for the work provided by the physician. 20. You are called to an outlying hospital to see a baby in the well baby nursery who has become clinically septic. You obtain blood cultures, perform a lumbar puncture and start antibiotics. The infant is placed on hood oxygen (FIO2 60%). After evaluating the baby and reviewing information, spending 50 minutes, you decide that baby needs to be transferred to a higher level of care. There is no available bed at your hospital and the baby is transferred to another group at an institution 30 minutes away. You are present during the transfer. Answer: C The proper code(s): a , , b , c , , Critical Care, evaluation and management of the critically ill or critically injured patient; first minutes. CPT 2008, page CPT Assistant Dec 06:13. Coding for Pediatrics 2008, page represents the code for a lumbar puncture (CPT 2008, page 268, CPT Assistant Nov 99:32-33, Oct 03:2, Jul o6:4, CPT Changes: An Insider s View 2000, 2002, Coding for Pediatrics 2008, page 89, 158, 189). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric parent, 24 months of age of less; first 30-74minutes of hands on care during transport. (CPT 2008, Page 18; CPT Assistant May 05, Jul 06:4;CPT Changes: An Insider s View 2002, Coding for Pediatrics 2008, page 88,

15 The above vignette describes a critical patient. Unlike the 99295, 99296, 99298, 99299, 99300, codes the code for the spinal tap (62270) is not bundled with the code. Endotracheal intubation is also not bundled with The following services however are bundled: the interpretation of cardiac output measurements (93561, 93562), chest CX rays (71010, 71015, 71020), pulse oximetry (94760, 94761, 94762), blood gases, and information data stored in computers (eg, ECGs, blood pressures, hematologic data (99090); gastric intubation (43752, 91105); temporary transcutaneous pacing (92953); ventilatory management ( , 94660, 94662); and vascular access procedures (36000, 36410, 36415, 36591, 36600). Documentation of the critical nature of this patient must be provided. 21. Mrs. and Mrs. Arnaz come to see you because their first child, Ricky had gastroschisis. Lucy is pregnant and she and Ricky are new to Los Angeles. They would like to know what the capabilities are in your NICU if this baby has a similar problem. Their obstetrician, Dr. Mertz has not indicated that there is a problem with this pregnancy. You spent 30 minutes with them. Answer: B The proper code: a b c Preventive medicine counseling and /or risk factor reduction interventions(s) provided to an individual (separate procedure; approximately 30 minutes. CPT 2008, page 33, CPT Assistant Aug 97:1, Jan 98, May 05:1. Coding for Pediatrics 2008, page Preventive medicine individual counseling codes ( ) may be reported if the family comes to the neonatologist either self-referred or sent by another provider to discuss a risk reduction intervention (ie, seeking advice to avoid a further problem or complication. These codes are reported based upon the time spent providing the counseling. Because they are time-based codes, the medical record must include documentation of the total counseling time and summary of the issues discussed. Another coding approach would be to not use the consultation codes but to use the office visit codes ( ), home service ( ) or domiciliary/rest home care codes ( ). 22. Mrs. Abbott is admitted at 26 weeks with preterm labor. Her obstetrician, Dr. Costello, asks you to see Mrs. Abbott for an inpatient consultation. You spend 45 minutes speaking with Mr. and Mrs. Abbott about the risks of premature delivery and dictating the consult. Mrs. Abbott s labor abates and she is kept in the hospital on bed rest. She is treated with tocolytics and steroids. At 30 weeks, she again begins to contract. Delivery seems imminent and inevitable. Dr. Costello asks you to speak with Mr. and Mrs. Abbott again. You spend 30 minutes with the family. The proper code for the 1 st consult is: a b c Answer: C 15

16 99252 represents an inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history, an expanded problem focused examination; and straightforward medical decision making. In general, an inpatient consultation code is used only once by the reporting physician for an individual hospital patient for a particular episode of care. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient s hospital floor or unit. Both the requesting and consulting physician must document the request in the medical record. CPT 2008, page 16, CPT Assistant Sep 02:11; CPT Changes: An Insider s View 2007, Coding for Pediatrics 2008, page 86). Answer: A The proper code for the 2 nd consult is: a b c represents a subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two of these three key components; an expanded problem focused interval history; an expanded problem focused examination; medial decision making of moderate complexity. (CPT 2008, page 13, CPT Assistant March 07; Coding for Pediatrics 2008 page 95). Only one consultation can be reported by a consultant per admission. Subsequent services during the same admission are reported using subsequent hospital care codes which include services to complete the initial consultation, monitor progress, revise recommendations, or address a new problem. The selection of these codes is based upon physician time spent during the consultation. Physicians typically spend 40 minutes at the bedside and on the patient s hospital floor or unit for a code and 25 minutes at the bedside and/on the patient s hospital floor or unit for a code. Other consultation codes similar to this example utilizing time are as follows: (20 minutes); (55 minutes); (80 minutes); (110 minutes). Other subsequent follow-up codes for continual services include: (15 minutes); (35 minutes). 23. Mr. and Mrs. Cramden are referred by their obstetrician for an outpatient consultation. Their fetus, conceived on their honeymoon, was noted to have a unilateral dysplastic kidney and complex congenital heart disease by their perinatologist, Dr. Norton. You spend 20 minutes reviewing Alice s records including the prenatal ultrasound and fetal echocardiogram. At the time of the consultation, you spent 1 hour with the couple, since Ralph had many questions. It took another 20 minutes to dictate and proof read your letter back to Dr. Norton. Answer: A The proper code for this consultation is: a , b c prolonged evaluation and management service before and/or after direct (face-to-face) patient care (eg, review of extensive records and tests, communication with other professionals and /or the patient/family); first hour (list separately I addition to code(s) for other physician service(s) and/or inpatient or outpatient Evaluation and Management service) CPT 2008, page 29, CPT Assistant Nov 05:10. Coding for Pediatrics 2008 pages 64-65, 96 16

17 99244 represents an office consultation for a new or established patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Usually the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family. CPT 2008, page 15, CPT Assistant April 07:11, Coding for Pediatrics 2008 pages 62, 209 The code can be used initially for record review and management services before and after the face-to-face meeting. There is no RVU for The face-to-face part of this consultation is only 60 minutes and therefore this is the code to be utilized. If the review of the ultrasound and the records were done face-to-face with parents as well, (80 minutes) could be used. 24. Baby boy Keaton is born at a community hospital and your hospital is called to transport the baby. You send the transport team which is composed of a nurse practitioner and a respiratory therapist. You speak to the NNP several times and give her direction in terms of the management. The baby is having respiratory distress and is intubated, given surfactant and an umbilical artery catheter is placed. When the baby arrives at your hospital you admit this intubated, critically ill baby. The NNP is employed by the hospital. Answer: A The proper code(s) are: a , b , 31500, 94610, 36660, c represents physician direction of emergency medical systems (EMS, emergency care, advance life support). The physician directs the performance of necessary medical procedures. This physician directed transport team does not apply for in-house transport. The physician and team remain in 2-way communication and decide together on the appropriate management and intervention. The supervising physician cannot code the actual procedures and interventions provided by the team unless he/she is physically present with the team during transport. Although the code should be reported, there is no RVU or reimbursement for this code. (CPT 2008 page 18; CPT assistant, May 05:1; Coding for Pediatrics 2008, page represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) In directed emergency care, the physician is in two-way voice communication with the rescue personnel outside the hospital. The physician directs the performance of necessary medical procedures. The physician and team remain in two-way communication and decide together on the appropriate management and interventions for the child during transport. If this communication is with the neonatal nurse practitioner (NNP) and the NNP is employed by the hospital the neonatologist cannot report a code for that service. If the NNP is on the transport 17

18 team and is employed by the neonatal group, the NNP can report the transport codes if the State of practice allows an independent billing number and the activities are covered in the scope of practice. In addition, in some states, if the NNP is employed by the neonatal group she is considered an extension of the neonatal group and the group s provider number can be used. Although the code should be reported, there is no RVU or reimbursement for this code at this time. 25. Baby girl Allen is born at 28 weeks gestation at a level one center and Dr. Burns calls you to come pick the baby up. You receive the call at 1:00 am. The transport team including the neonatologist is ready to leave at 1:20 am and arrives at the referring hospital at 2:00 am. The neonatologist spends 1.5 hours evaluating the baby. Included in this time are 10 minutes to intubate and administer surfactant and 20 minutes to place umbilical venous and arterial catheters. They leave the referring hospital at 3:30 am and arrive at the level 3 center at 4:15 am. The neonatologist admits the baby. Answer: B The proper code(s) are: a , x2, 26510, 36660, 21500, 94610, b , 99290, , , , c , x2, Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric parent, 24 months of age of less; first 30-74minutes of hands on care during transport. (CPT 2008, Page 18; CPT Assistant May 05, Jul 06:4;CPT Changes: An Insider s View 2002, Coding for Pediatrics, page each additional 30 minutes (List separately in addition to code for primary service) CPT 2008, page 18. CPT Changes: An Insider s View 2002 (Use in conjunction with 99289) Coding for Pediatrics 2008, page Catheterization of umbilical vein for diagnosis or therapy, newborn (CPT 2008, page 170; CPT Assistant Jul 06:4; Coding for Pediatrics 2008, page 119, 218). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Catheterization, umbilical artery, newborn, for diagnosis or therapy. CPT 2008, page 174, CPT Assistant Jul 06:4, CPT Changes: An Insider s View Coding for Pediatrics 2008, pages 119, is a procedure code for endotracheal intubation. (CPT 2008, page 135; CPT Assistant Jul 06:4; Coding for Pediatrics 2008, page 117) Intrapulmonary surfactant administration by a physician through endotracheal tube (CPT 2008, page 413; CPT Changes: An Insider s View 2007; Coding for Pediatrics 2008, page 88-89). 18

19 99295 represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) Codes 99289, report physical attendance and direct face-to-face care by a physician during the interfacility transport of a critically ill patient <24 months of age. The infant s condition must meet the CPT definition for critical care. Services bundled under and are the same services that are bundled with the hourly critical care codes (99291, 99292). These defer from the bundled services that are part of the neonatal critical care codes (99295, 99296). The code for umbilical vein catheterization (36510); umbilical artery catheterization (36660); endotracheal intubation (31500) and Surfactant administration (94610) are not bundled under the transport codes (99289, 99290). The total time spent with the patient is 90 minutes in the beginning and then 45 minutes in transport for a total of 135 minutes. Subtracted from this is 30 minutes for the procedures. Therefore the total time is 105 minutes is minutes and adds an additional 30 minutes. 26. Baby girl Lewis is delivered at 27 weeks by c-section for maternal indications. Dr. Martin attends the delivery, resuscitates the baby with PPV and as part of the resuscitation intubates and gives surfactant in the delivery room. The baby is then transferred to the NICU where Dr. Martin places an umbilical artery catheter and writes up a complete history and physical. Answer: A The proper codes are: a , , , b , 31500, 94610, 99295, c , represents an attendance at delivery with resuscitation including positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output. (CPT 2008, page 34; CPT Assistant Apr 07:3; Coding for Pediatrics 2008, page 90-91) is a procedure code for endotracheal intubation. If the intubation is performed in the delivery room as an essential component of the resuscitation, it is reported separately. (CPT 2008, page 135; CPT Assistant Jul 06:4; Coding for Pediatrics 2008, page 117). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163). 19

20 94610 Intrapulmonary surfactant administration by a physician through endotracheal tube. If the procedure is done as part of the resuscitation it may be reported. If this procedure is done in the NICU it is bundled under the global critical care code. There are very few instances where Surfactant is necessary component of resuscitation in the delivery room. (CPT 2008, page 413; CPT Changes: An Insider s View 2007; Coding for Pediatrics 2008, page 88-89) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) If the Surfactant administration (94610) is utilized as part of the resuscitative process it can be coded separately. The physician must play an active role in this process. Observing the respiratory therapist or NNP giving the surfactant does not satisfy criteria. There must be hands-on participation in order to use this code. 27. Baby boy Stiller is born at term by the vaginal route. Dr. Meara is asked to attend the delivery due to some late decelerations on the fetal monitor strip. Baby boy Stiller is breathing spontaneously but the lungs sound wet. Dr. Meara applies a CPAP device to the baby for 2 minutes after which time the baby improves. The baby goes to the term nursery under another physician s care. Answer: C The proper code is: a b c represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91). CPAP which is utilized to remove fluid from the lungs without positive pressure does not constitute resuscitation and the need for Baby boy Carson was born full term without any apparent health problems. Dr. Severinson sees the baby in the morning and does routine newborn care. Four hours later Dr. Severinson receives a call from nurse McMahon who tells him that baby boy Carson appears cyanotic. Dr. Severinson tells her to begin oxygen therapy while he drives in from his office. When he arrives, he finds that the baby has a loud holosystolic murmur and 20

21 decreased pulses in the lower extremities. He gets blood gases, chest x-ray, and blood pressure measurements, CBC, and blood cultures. Antibiotics are given. The baby is transferred to the NICU. Dr. Severinson calls the pediatric cardiologist who based on the data she is given, tells Dr. Severinson to start prostaglandin until she can get there to perform the echocardiogram. Answer: B The proper code(s) are: a b , c , represents the history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. (CPT 2008, page 33; CPT Assistant May 05:1 Coding for Pediatrics 2008, page modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) The code can be used initially for the baby was considered a normal newborn. Later on when there was change in status, the neonatologist evaluated, stabilized and started medication for cardiac disease. The code states that preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code. 29. Baby Tooley is a 930 gm 27 wk infant on day 8. He was on 1.5 Liters High Flow nasal canula simulating CPAP but despite caffeine was having multiple apnea and bradycardia events requiring bag and mask stimulation. He was placed on CPAP at 5 cm and room air. The apnea and bradycardia events improved. He is on trophic feedings day 4/5 of 10ml/kg/ day of breast milk and TPN via a central PICC line. Answer: A The proper code is: a b c

22 99296 represents a subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate 28 days or less. A critically ill neonate will require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations throughout a 24-hour period, and constant observation by the health care team under direct physician supervision. (CPT 2008, page 21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) This baby can be considered critical if the high flow nasal canula which simulates nasal CPAP represents a therapy which if removed would lead to a high probability imminent or lifethreatening deterioration of the patient s condition. There is no definition for the timeframe of imminent or life-threatening deterioration. The physician must use his or her judgment in assigning this definition. To demonstrate the appropriate application of a critical care code the physician must clearly document in the medical record the child s condition and instability along with the risks to the patient and the frequency of needed assessment and interventions. 30. Baby Gregory is a 3.2 Kg. infant 35 day old infant now corrected to 37 weeks gestational age post gastroschisis repair being drip fed an elemental formula. He developed signs of sepsis, necrotizing enterocolitis and DIC. He is intubated, placed on High Frequency (HFOV) ventilation prior to exploratory laparotomy. Answer: A The proper code is: a b c represents a subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. This code is bundled and procedures may not be reported separately. CPT 2008 page 21, CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics As baby is >28 days, and this is critical care is the correct code. 31. Baby Smith is a 2 day old 435 gram 23 week premature infant on HFOV and 80% oxygen. Answer: A The proper code for day is: a b c represents a subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate 28 days or less. A critically ill neonate will require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations throughout a 24-hour period, and constant observation by the health care team under direct physician supervision. (CPT 2009, page 21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) 22

23 This baby is only two days old and satisfies the criteria for subsequent day critical care. 32. Baby Apgar is a 90 day old former 24 wk premature who weighs 2.1 Kg and who remains on caffeine for apnea and diuretics and pulmicort and and oxygen at 100mL flow. He is being discharged to his parents on a home monitor, oxygen and the above medications. Time spent 40 minutes. Answer: C The proper code for the discharge day is: a b c represents a code which reports total duration of time spent by a physician for final hospital discharge of a patient. The code includes a final examination, discussion of the hospital stay (the time does not have to be continuous), instructions for continuing care to all relevant caregivers and preparation of discharge records, prescriptions and referral forms. This code represents hospital discharge day management; 30 minutes or more. (CPT 2008 page 14, CPT Assistant Sept 06:8; Coding for Pediatrics 2008, page 58-59). Documentation remains most important and there must be a place in the discharge note for detailing the discussion with the parents. Years later if a malpractice action is filed, the documentation will serve to assist the neonatologist if he/she is cited for not speaking in detail to the parents 33. Baby Harvey is a former 36 week 14 day old late preterm infant who weighs 2. 8 Kg being discharged today to parents breast feeding every two to three hours. He is to follow up in two days with his primary care physician. Time spent 23 minutes. Answer: A The proper code for discharge is? a b c Hospital discharge day management; 30 minutes or less reported by attending physician providing discharge services on a date other than the day of admission. The reporting is based on the total time (time does not have to be continuous) spent performing all final discharge records. These codes may be used to report discharge services provided to patients who die during their hospital stay. CPT 2008 page 14, CPT Assistant Sep 06:8, Coding for Pediatrics 2008 pages You are called to the c-section delivery of a 28 week infant. His Apgars are 6 and 7, and he has an adequate respiratory drive and a normal cry for his gestational age. His weight is 800 grams. He requires intubation for respiratory distress and is given a prophylactic dose of surfactant by the nurse and RT, then extubated and placed on CPAP. He has an O2 saturation of 92%, but his perfusion is poor. You place an Umbilical venous line, administer 8 ml of normal saline, then transport the infant to the NICU where he is continued on CPAP. 23

24 Answer: A The proper codes are: a , b , , , c , represents attendance at delivery with resuscitation including positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output. (CPT 2008, page 34; CPT Assistant Apr 07:3; Coding for Pediatrics 2008, pages 90-91) Catheterization of umbilical vein for diagnosis or therapy, newborn (CPT 2008, page 170; CPT Assistant Jul 06:4; Coding for Pediatrics 2008, page 119, 218) Intrapulmonary surfactant administration by a physician through endotracheal tube. If the procedure is done as part of the resuscitation it may be reported. If this procedure is done in the NICU it is bundled under the global critical care code. There are very few instances where Surfactant is necessary component of resuscitation in the delivery room. (CPT 2008, page 413; CPT Changes: An Insider s View 2007; Coding for Pediatrics 2008, page 88-89) is a procedure code for endotracheal intubation. If the intubation is performed in the delivery room as an essential component of the resuscitation, it is reported separately. (CPT 2008, page 135; CPT Assistant Aug 06:4; Coding for Pediatrics 2008, page modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) In the example represented above, the Surfactant was utilized prophylactically and was not an integral part of the resuscitative process. Therefore the code for endotracheal intubation (31500), and the code for surfactant administration (94610) is not utilized. 35. You are asked by a pediatrician to examine a newborn infant in the regular nursery with several minor dysmorphic features and recommend whether a karotype analysis is indicated. You perform a complete physical exam and determine that while a chromosomal anomaly is not likely, karyotype is indicated. You discuss your findings with the infant s parents and relay your opinion to the pediatrician by telephone. Time spent 45 minutes. 24

25 Answer: B The proper code is: a b c represents an inpatient consultation for a new or established patient, which requires these three key components: an expanded problem focused history, an expanded problem focused examination; and straightforward medical decision making. In general, an inpatient consultation code is used only once by the reporting physician for an individual hospital patient for a particular episode of care. Usually, the presenting problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient s hospital floor or unit. Both the requesting and consulting physician must document the request in the medical record. CPT 2008, page 16, CPT Assistant Sep 02:11; CPT Changes: An Insider s View 2007, Coding for Pediatrics 2008, page 86). These consultation codes are time based. Code is used if minutes is spent in consultation represents minutes; from minutes; from 80 minutes to 110 minutes. Documentation is extremely important when utilizing any of these consultation codes. 36. You are caring for an 1854gram infant, now 10 days old. He initially had severe RDS, requiring mechanical ventilation, but has since been weaned first to NCPAP and now to 3 lpm high flow nasal cannula oxygen (35%) to simulate CPAP. He remains tachypneic but has normal arterial blood gases. He is receiving parenteral nutrition as well as enteral feedings at 80 ml/kg/day. Answer: B The proper code is: a b c represents a subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate 28 days or less. A critically ill neonate will require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations throughout a 24-hour period, and constant observation by the health care team under direct physician supervision. (CPT 2009, page 21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) In the example above the question remains that if high flow nasal cannula is used to simulate NCPAP, does this alone satisfy the criteria for being critical? In order for this to be true the patient must satisfy CPT definitions where a critical illness impairs one or more vital organs a high probability of imminent or life-threatening deterioration of the patient s condition if the therapy is withdrawn. The documentation provided must satisfy this criteria. 25

26 37. You have been asked by an obstetrician to counsel a family that has just been informed their 30 week fetus has an apparent bowel obstruction on fetal ultrasound. You meet with the family for 30 minutes in your office and discuss the differential diagnosis of in utero bowel obstruction, including possible genetic causes. You spend an additional 15 minutes drafting a consult letter to the obstetrician. Answer -C The proper code is: a b c represents an office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Usually the presenting problem(s) are of low severity.. Physicians typically spend 30 minutes face-to-face with the patient and/or family. CPT 2008, page 5, 15, CPT Assistant Apr 07:11 Coding for Pediatrics 2008 pages 62, 209 It is important to remember that time spent in the office/out patient can only utilize face-toface time. Post service time (a report) cannot be added when selecting the typical time used with this code. This differs from the unit/floor time service which incorporates non face-toface pre and post time. Physicians typically spend 30 minutes face-to-face with the family in a scenario. The additional 15 minutes can not be added since this was not face-to-face. 38. A 2400 g infant is transferred to you from the normal newborn nursery for persistent tachypnea and retractions. You perform a complete history, physical exam, and laboratory workup, including a percutaneous arterial blood gas and lumbar puncture. You admit him to the NICU, begin antibiotics and the baby is placed on 3 lpm nasal cannula(60% oxygen) in order to simulate NCPAP. Answer B The proper code is: a b c represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) 26

27 NCPAP is a criteria for a critical care code only if there is documentation of the critical nature of the illness. Remember that the expression a high probably imminent or life threatening deterioration of the patient s condition should be part of the physician s note. 39. A 14 day old infant now weighs 900 grams. She continues to require nasal cannula oxygen 0.5 lpm, and is receiving caffeine for occasional apnea. She is on 60 ml/kg/day of enteral feeds and 60 ml/kg/day intravenous alimentation. Answer C The proper code is: a b c represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight less than 1500 g). Infants with present boy weight less than 1500 grams who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. This is a global code and all procedures are included in the code and are not reported separately (CPT 2008, page 22; CPT Assistant 11/05:10; CPT Changes: An Insider s View 2003; Coding for Pediatrics 2008, page 100, 103, 104). This is a weight-base intensive care code (<1500 grams) and the intravenous alimentation is bundled as part of the code. 40. Term infant with good prenatal care was delivered by normal spontaneous vaginal delivery and sent to NBN where it was noticed in visual inspection by the nurses to have an imperforate anus. Neonatologist was called and baby was then transferred to NICU, made NPO and awaiting surgical consultation. Surgery was performed later that day. Answer A The proper codes are: a b , c represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) 27

28 CPT 2008 in their description of states immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code the question remains is an imperforate anus a life threatening surgical condition. The coding committee believes that if surgery is performed on the same day that this baby satisfies the criteria for a critical care code. If surgery was done the following day then is the correct code (normal newborn care) should not be included in the answer since the baby was not seen by the neonatologist in the newborn nursery as a normal newborn. 41. Term infant in the newborn nursery was noticed by the pediatrician to have a dislocation of the hip and was concerned about mild dysplasia to frank dislocation. She consults with the neonatologist and requests that the neonatologist verify the hip instability by examination. The neonatologist agrees with the pediatrician s assessment, and provides a detailed history, detailed physical examination and low complexity decision making. The pediatrician requests that the neonatologist assume care. Infant remains in the newborn nursery. Answer - C The proper code is: a b c represents an inpatient consultation for a new or established patient, which requires these three key components: a detailed history, a detailed examination; and medical decision making of low complexity. In general, an inpatient consultation code is used only once by the reporting physician for an individual hospital patient for a particular episode of care. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient s hospital floor or unit. Under the revised CMS consultation standards, both the requesting and the consulting physician (or other provider) must document the request in the medical record. (CPT 2008, page 16, CPT Assistant Sep 02:11; CPT Changes: An Insider s View 2007, Coding for Pediatrics 2008, page 67-68). Note that the code requires the components of a detailed history, a detailed examination and decision making of low complexity. In the example above these statements provide enough information to utilize the code. If the history and physical examination was comprehensive and the decision making was at moderate complexity then would be the correct code. For the criteria necessary for these codes see Coding for Pediatrics 2008 page A term infant is delivered to a mother with no prenatal care, unknown GBS status, and maternal fever The mother receives one dose of antibiotics six hours before delivery. The infant is taken to the newborn nursery and is admitted by the neonatologist. A CBC and blood culture are taken by the nurse. There are no other signs or symptoms and infant begins feeding. The proper code is: a b c Answer B 28

29 99431 represents the history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records.. (CPT 2008, page 33; CPT Assistant May 05:1, Coding for Pediatrics 2008, page 92, 93). This is a common scenario where the baby appears normal but the history necessitates a further evaluation. Since there are no clinical signs which would place this baby as not normal, a is appropriate. 43. The Neonatologist is called to see a mother in labor in the ED; a consultation is done but the patient is not admitted. Neo spends 30 minutes face to face. Answer B The proper code: a b c represents an office consultation for a new or established patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making. Usually the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family. CPT 2008, page 5, 15, CPT Assistant Apr 07:11 Coding for Pediatrics 2008 pages 62, 209 The ED department represents an outpatient consultation. In this case the mother is never admitted to the hospital. The code is a perinatal counseling and consultation code with no defined symptom or established illness. The code is an inpatient consultation. Therefore the code is used since 30 minutes of face-to-face time was utilized. 44. The neonatologist attempts to place a PICC line in a 1800 gram infant, but is unsuccessful. Answer B The proper codes are: a , b c , represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. (CPT 2008, page 22; CPT Assistant 11/05:10. Coding for Pediatrics 2008, page ). 29

30 36555 Insertion of non-tunneled centrally inserted central venous catheter, younger than 5 years of age. To qualify as a central venous access catheter or device, the tip of the catheter/device must terminate in the subclavian, brachiocephalic (innominate) or iliac veins, the superior or inferior vena cava, or the right atrium. The venous access device may be either centrally inserted (jugular, subclavian, femoral vein or inferior vena cava catheter entry site) or peripherally inserted (eg, basilica or cephalic vein). The device may be accessed for use either via exposed catheter (external to the skin), via a subcutaneous port or via a subcutaneous pump. CPT 2008, pages 170, 171.CPT Assistant Dec 04:7, Jul 06:4, CPT Changes: An Insider s View Coding for Pediatrics 2008, page 89, 119. In this example the code is not utilized for this procedure (insertion of a PICC line) is bundled under For a complete description of bundled verses not bundled services in both critical care and intensive care situations see Coding for Pediatrics 2008 page Baby Doe is born at 26 weeks gestation. The Neonatologist attends the delivery. The child is born depressed with gasping respirations and the infant is intubated by the neonatologist. The infant does not respond well to hand ventilation. A decision to give intra-tracheal surfactant down the ET tube is made and the surfactant is delivered. The infant pinks up shortly after this, heart rate improves, and the child becomes easier to ventilate. The infant is moved to the NICU and admitted. Answer - B The proper codes are: a , , b , , , c , 99436, 31500, represents an attendance at delivery with resuscitation including positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output. (CPT 2008, page 34; CPT Assistant Apr 07:3; Coding for Pediatrics 2008, pages 90-91) is a procedure code for endotracheal intubation. If the intubation is performed in the delivery room as an essential component of the resuscitation, it is reported separately. (CPT 2008, page 135; CPT Assistant Aug 06:4; Coding for Pediatrics 2008, page 117). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Intrapulmonary surfactant administration by a physician through endotracheal tube. If the procedure is done as part of the resuscitation it may be reported. If this procedure is done in the NICU it is bundled under the global critical care code. There are very few instances where Surfactant is necessary component of resuscitation in the delivery room. (CPT 2008, page 413; CPT Changes: An Insider s View 2007; Coding for Pediatrics 2008, page 88-89) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and 30

31 constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) In this example the use of (endotracheal intubation) and (Surfactant administration) is correct for these services were provided in the delivery room and is part of the resuscitative process. Documentation must include these criteria. A -59 modifier must be used to alert the payer that this is a distinct procedural service. 46. You attend a delivery of a 29 week infant. The infant requires resuscitation including endotracheal intubation and positive pressure ventilation. The infant is brought to the NICU and admitted. A UAC and UVC is placed and the child is given surfactant. Answer C The proper codes are: a , , 99295, 36660, 36510, b , c , , represents an attendance at delivery with resuscitation including positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output. (CPT 2008, page 34; CPT Assistant Apr 07:3; Coding for Pediatrics 2008, pages 90-91) is a procedure code for endotracheal intubation. (CPT 2008, page 135; CPT Assistant Aug 06:4; Coding for Pediatrics 2008, page 117). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) The endotracheal intubation code is used with a -59 modifier since this procedure was part of the resuscitative process in the delivery room. The UAC (36660) and UVC (36510) are placed in the NICU and are bundled. 31

32 47. You are called to the delivery of a 31 week infant delivered by c-section due to failure to progress. Apgar scores are 6(1) and 8(5). The infant begins grunting in the delivery room. You apply CPAP by nasal prongs. The child is admitted to the NICU on CPAP and a UAC is placed. Within 6 hours the infant is off CPAP on room air in no further respiratory distress. Answer C The proper codes are: a , b , 99477, c , represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) The reason that is chosen rather than is that the CPAP is used to clear lung fluid and is not positive pressure ventilation. The UAC (36660) is placed in the NICU and is bundled. In order to use a code documentation must support the critical nature of the baby s illness. 48. A 35 week (2300 gram) infant is admitted to the NICU in mild respiratory distress. The infant is placed in a 35% oxyhood and a blood gas is acceptable. A peripheral IV is started and the child is placed on a continuous heart rate, respiratory, and saturation monitor. Blood cultures are drawn and antibiotics are started. The initial blood glucose is 23 mg/dl and a bolus of IV glucose is given. The glucose normalizes and the infant remains in an oxyhood in 25% oxygen for the next two days. The proper code for Day One is: Day Two: a a b b c c Answer Day One - C Answer Day Two B 32

33 99477 Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ) represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. From the information given this baby does not appear to be critical and there is not a high probability of imminent or life-threatening deterioration of the patient s condition. This patient is under constant observation by the healthcare team under direct physician supervision. CPT 2008, page 22; CPT Assistant 11/05:10. Coding for Pediatrics 2008, page The baby as described in the vignette is not critical. A low glucose (23mg/dL) which responds without the need for frequent changing of IV solutions or clinical symptoms make this baby an intensive care admission (99477). On day two the baby is still considered intensive and a weight-based code is used. 49. A mother at 25 weeks gestation enters the hospital with ruptured membranes in early labor. Her obstetrician asks you to consult to tell her about prematurity, risks, and what to anticipate. You go to the labor deck and review the maternal records and her hospital course up to that time. You then speak to the mother and her husband and answer all of their questions. You write a consult note to the obstetrician and leave a copy on the mother s chart. The entire consult time is 65 minutes. The time spent face-to-face is 50 minutes. Answer C The proper code is: a b c represents an inpatient consultation for a new or established patient, which requires these three key components: a detailed history, a detailed examination; and medical decision making of low complexity. In general, an inpatient consultation code is used only once by the reporting physician for an individual hospital patient for a particular episode of care. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient s hospital floor or unit. Under the revised CMS consultation standards, both the requesting and the consulting physician (or other provider) must document the request in the medical record. (CPT 2008, page 16, CPT Assistant Sep 02:11; CPT Changes: An Insider s View 2007, Coding for Pediatrics 2008, page 86-87) is chosen for an inpatient hospital consultation code based upon time includes pre and post time which is added to the face-to-face time. This is different then an outpatient 33

34 consultation (99244). The code which is a perinatal counseling and consultation code has no defined symptom or established illness (60 minutes) (55 minutes) is used for is 80 minutes of total time. The total time (pre, face-to-face, post) is 65 minutes. If this time reached 80 minutes would have been correct. 50. You are called to the delivery of a 40 week gestation infant who is to be delivered by C/S due to sustained bradycardia. At delivery the infant is apneic, bradycardic and limp. You intubate the infant to provide ventilation. Cardiac massage is given for 30 seconds. Although the heart rate improves, pulses are barely palpable and you insert an umbilical venous line and give a normal saline bolus. The infant is now more stable and is admitted to the NICU for continued respiratory failure. Answer A The proper codes are: a , , , b , , , c , , , represents an attendance at delivery with resuscitation including positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output. (CPT 2008, page 34; CPT Assistant Apr 07:3; Coding for Pediatrics 2008, pages 90-91) is a procedure code for endotracheal intubation. If the intubation is performed in the delivery room as an essential component of the resuscitation, it is reported separately. (CPT 2008, page 135; CPT Assistant Aug 06:4; Coding for Pediatrics 2008, page 117) Catheterization of umbilical vein for diagnosis or therapy, newborn (CPT 2008, page 170; CPT Assistant Jul 06:4; Coding for Pediatrics 2008, page 119, 218). -25 modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) represents the initial neonatal critical care code for the evaluation and management of a critically ill neonate 28 days or less. Critically ill neonates require cardiac and/or respiratory support (including ventilator or nasal CPAP when indicated), continuous or frequent vital sign monitoring, laboratory and blood gas interpretations, follow-up physician reevaluations, and constant observation by the health care team under direct physician supervision. Immediate preoperative evaluation and stabilization of neonates with life threatening surgical or cardiac conditions are included under this code (CPT 2008, page 20-21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008, page 96-99) 34

35 Distinguishing modifiers is sometimes difficult. A -59 modifier indicates that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures/services that NOT normally reported together but are appropriate under the circumstances. This modifier also alerts the payer that there is a distinct independent service performed on the same day. The -25 modifier is used when a procedure or service identified by a CPT code is performed and the patient s condition requires a significant separately identifiable E/M service above and beyond the other service provided. 51. A term infant has been in the nursery for treatment of pneumonia. Today he is to be discharged. You spend 20 minutes with the family going over discharge instructions. You also circumcise the infant with a penile block prior to discharge. Answer - C The proper code is: a , , b , c , Hospital discharge day management; 30 minutes or less reported by attending physician providing discharge services on a date other than the day of admission. The reporting is based on the total time (time does not have to be continuous) spent performing all final discharge records. These codes may be used to report discharge services provided to patients who die during their hospital stay. CPT 2008 page 14, CPT Assistant Sep 06:8, Coding for Pediatrics 2008 pages modifier represents a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. The physician may need to indicate that on the day that this procedure or service was performed, the patient s condition required a significant separately identifiable E/M service above and beyond the other service or procedure provided. (CPT 2008 page 457; Coding for Pediatrics 2008 page 156, 157) modifier represents reduced services. When a service or procedure is partially reduced or eliminated at the physician s discretion, modifier 52 should be appended to the procedure code. This provides a mean of reporting reduced services without disturbing the identification of the basic service. CPT 2008, page 457. Coding for Pediatrics 2008, page modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Circumcision using the clamp or other device with regional dorsal penile or ring block. CPT 2008, page 237, Coding for Pediatrics 2008, page was previously reported when a dorsal penile block was utilized. This has now been replaced by which describes a circumcision with regional dorsal penile or ring block. If a circumcision is done without a dorsal penile or ring block a is used with a -52 modifier which represents reduced services. 35

36 52. This is DOL 62 for this ex 620 gm 24 week gestation male infant with history of RDS, electrolyte abnormalities, anemia and clinical NEC. He is now 1200 gms on RA NCPAP. He continues to have moderate episodes of bradycardia with desaturations, requiring stimulation. He is on full gavage feeds and continues on caffeine. Answer - C The proper code is: a b c represents a subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age. This code is bundled and procedures may not be reported separately. (CPT 2008, page 21; CPT Assistant Nov 05:10; CPT Changes: An Insider s View 2005; Coding for Pediatrics 2008 pages 96-99). The question here is whether or not this baby is critical. Documentation must again reflect the critical nature of this baby s illness and that withdrawal of the therapy leads to a high probably imminent or life threatening deterioration of the patient s condition. If this perimeter is not present than a weight-based intensive care code <1500 grams would be selected. 53. This is a day old term infant born to a mother with history of fever and ROM x 18hours. GBS status is unknown. The neonatologist attends the delivery and admits the baby to the regular nursery. The neonatologist draws a CBC and blood culture and infant is sent to the regular nursery in good condition. At about 12 hours of age infant develops tachypnea and grunting. The NNP sees the patient and after consultation with the neonatologist the patient is admitted to the NICU. He is made NPO, an IV with D10W started. Antibiotics are begun and the baby was placed on nasal cannula flow (1L at 25% oxygen concentration). The neonatologist sees him the next morning. (NNP is employed by the hospital) Answer C The initial proper code is a , b , c , , represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91). 36

37 -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Venipuncture, age <3 years necessitating physician s skill, not to be used for routine venipuncture; femoral or jugular vein. CPT 2008, page 169. Coding for Pediatrics 2008, page 89, represents the history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records.. (CPT 2008, page 33; CPT Assistant May 05:1, Coding for Pediatrics 2008, page 92, 93) is used since this is a simple attendance at delivery without resuscitation. A code for venipuncture ( ) is placed the neonatologist obtains the blood sample personally. The baby is admitted as a normal newborn (99436) Answer C The proper code for 12 hours of age is: a b c. no code Since the NNP is employed by the hospital the neonatologist can not place a code for supervision. Therefore there is no code offered for her service. If the NNP has her own pin (billing) number she can submit a separate code for the admission. It is necessary to check with State requirements which vary. Answer B The proper code for the following morning: a b c Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring.infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). The following morning the neonatologist interacts with the patient for the first time. This baby is not critical and therefore even though the patient was admitted to the NICU the night before, this is the first time the physician has seen the patient in the NICU. Therefore a noncritical code is utilized. 37

38 54. This is a day old (3150 grams) term infant born to a mother with history of fever and ROM x 18 hours. GBS status is unknown. The neonatologist attends the delivery and admits the baby to the regular nursery. The neonatologist draws a CBC and blood culture and infant is sent to the regular nursery in good condition. At about 12 hours of age infant develops tachypnea and grunting. The NNP sees the patient and after consultation with the neonatologist the patient is admitted to the NICU. He is made NPO, an IV with D10W started. Antibiotics are begun and the baby was placed on nasal cannula flow (1L at 25% oxygen concentration). The neonatologist sees him the next morning. (NNP is employed by the neonatal group) Answer C The initial proper code is a , b , c , , represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91). -59 modifier is used to indicate that a procedure or service was distinct or independent from other services performed on the same day. Only use this modifier if it best explains the circumstances and no other, more descriptive, modifier is available. (CPT 2008, page 458; Coding for Pediatrics 2008, page 157, 163) Venipuncture, age <3 years necessitating physician s skill, not to be used for routine venipuncture; femoral or jugular vein. CPT 2008, page 169. Coding for Pediatrics 2008, page 89, represents the history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records.. (CPT 2008, page 33; CPT Assistant May 05:1, Coding for Pediatrics 2008, page 92, 93) is used since this is a simple attendance at delivery without resuscitation. A code for venipuncture ( ) is placed the neonatologist obtains the blood sample personally. The baby is admitted as a normal newborn (99436) Answer A The proper code for 12 hours of age is: a b c. no code 38

39 99477 Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring.infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). Since the NNP is employed by neonatology group she can be considered an extension of the neonatologist. Therefore she can code for her service utilizing either the neonatologists ID number or her own pin (billing) number if allowed. It is necessary to check with State requirements which vary. Answer A The proper code for the following morning: a b c represents a subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of g). These infants are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, under direct physician supervision. (CPT 2008, page 22; CPT Changes: An Insider s View Coding for Pediatrics 2007, page 259). The neonatologist sees the patient the following morning and even though this is the initial NICU encounter he has already been credited with the admission the night before as the NNP is part of the neonatal group. The weight-based code is appropriate. 55. You are called to the delivery room to attend a delivery of a full term infant with a history of fetal distress and maternal pre-eclampsia. A stat C/S section is done with Apgar Scores of 6/8 at 1 and 5 minutes. Infant required suctioning and blow-by 02. Physical exam appeared to be normal except some mild hypotonia. Infant was observed in the NICU for 3 hours and then sent to the regular nursery. Answer B The proper codes are: a , b , c ,

40 99436 represents attendance at delivery and initial stabilization of newborn. Initial drying, stimulation, suctioning, blow-by oxygen or CPAP without positive-pressure ventilation, a cursory visual inspection of the neonate are included in the physician work associated with this code. A verbal request or written order and the reason for the request from the delivering physician should be documented in the attendance note. Use of this code should not be determined by a hospital policy but requires a request from the delivering physician. (CPT 2008, page 34, CPT Assistant Nov 05:15, Coding for Pediatrics 2008, page 90-91) represents the history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records.. (CPT 2008, page 33; CPT Assistant May 05:1, Coding for Pediatrics 2008, page 92, 93) is used as this is a delivery which was attended without the need for resuscitation. Suctioning and blow-by oxygen are parts of the code. The baby was observed in the NICU although not admitted. The place of service does not determine the code. Therefore the (normal newborn code) is appropriate. 56. Baby Boy Meyers, an 1190 gm infant at 29 weeks gestation is born at 1 AM. The delivery is attended by a neonatal nurse practitioner (NNP) who is employed by the hospital but works under the supervision of the neonatologist. The infant has respiratory distress and is intubated in the delivery room and given surfactant. The infant is admitted to the NICU and soon is extubated to CPAP. You are called by the NNP and informed about the delivery and the infant s condition. Management of the infant is discussed. You initially see and examine the infant at 7 AM, at which time the infant is now in an oxyhood in 40% oxygen. A peripheral IV is in place and the infant is receiving antibiotics. Answer - C The proper CPT code(s) for is: a , b , , c Initial hospital intensive care, per day, for the evaluation and management of the ill neonate, 28 days of age or less, who requires intensive observation and monitoring. Infants of any present body weight who are not critically ill but continue to require intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring and constant observation by the health care team under direct physician supervision.. (CPT 2008, page 35, CPT Changes: An Insiders View 2008, Coding for Pediatrics 2008, page ). Since the NNP is employed by the hospital the neonatologist can not code for the delivery. When the NNP is involved with the infant the baby is critical. However the first time the neonatologist examines the baby (at 7am) the infant is clearly not critical. Therefore although we are taught to utilize the highest acuity code for the day, at the time the baby becomes the neonatologist patient he is not critical. 40