Neonatal Transport Updates: Advances, Guidelines and Billing Codes
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1 Neonatal Transport Updates: Advances, Guidelines and Billing Codes Robert M. Insoft, M.D., F.A.A.P. Medical Director, NICU & Neonatal Respiratory Services Brigham & Women s Hospital Harvard Medical School Chairman, Section on Transport Medicine, American Academy of Pediatrics (rinsoft@partners.org)
2 Welcome to Scottsdale!
3 Disclosure Neither I nor any member of my immediate family has a financial relationship or interest with any proprietary entity producing health care goods or services related to the content of this CME activity. My content will not include discussion/ reference of any commercial products or services. I do not intend to discuss an unapproved/ investigative use of commercial products/devices.
4
5 Lecture Outline History of transport Novel Therapies & Equipment Newest guidelines from the Guidelines Coding & billing update Real case scenarios Transport crystal ball General discussion
6 History of Regionalized Transport Medical transports date back as early as Ceasar First transport isolette (1893) Newborn inter-hospital transport s Chicago Dept. of Health System s Assisted ventilation on transport s (France) Modern transport s (Usher, Canada)
7 Rotch-Putnam Incubator(circa 1893)
8
9 The Obstetrical Bag Transport Incubator (1922)
10 De Lee & Welde Transport Incubators (1920 s)
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12 Novel Therapies & Equipment ELBW (surfactant, thermoregulation) Inhaled Nitric Oxide ECMO Ventilators (HFOV) Brain Cooling
13 Novel Therapies & Equipment MRI Transport Incubator Capnography Wireless internet and more Telemedicine (consults, ECHO, U/S) Cong. Heart defects/transport to Cath Lab
14
15 Jesse et al., Air Medical J., 2004, 23(1): 17-19
16 ECMO: On Transport ECLS started at referring hospital Time is of the essence Must weigh benefit vs. risks and costs Team to include surgeons, neonatologists, perfusionists, RRT s, ECMO nurses Need to be equipped, self-sufficient for 24h Cornish (Wilford Hall Air Force Base) first to use portable ECMO on isolette (1987 & 1991) C-9 aircraft Now 16 year military experience (Wilson, Pediatrics, 2002) Three centers now available (Air Force, Michigan & Arkansas)
17 Wilson et al., Pediatrics 2002; 109:
18 ECMO Transport Centers -Univ. Michigan -Arkansas Children s -Wilford Hall, USAF, San Antonio
19 High Frequency Ventilation To treat severe RDS/ ARDS Minimizes barotrauma Uses low TV & high rates NICU units NOT portable Transport models being developed & tested, slow to market
20 High Frequency/ Jet Ventilation on Transport
21 Brain Hypothermia To Treat HIE Cooling the brain guards against further damage from initial hypoxic-ischemic injury Standard Rx in Cardiac OR s cooling to F minimizes HIE damage by minimizing apoptosis and necrotic cell death (Edwards, Thoreson et al.) Phase 2 & 3 trials on-going in neonatal population Hardware for NICU applications available Transport application may be next step!
22 Novel Equipment & Monitors: Good for Medicine? Internet on Transport Have we utilized it enough? Web based Cellular telephones Laptop & pocket hand-held computers Electronic database & med records Global Positioning System equipment ( e.g. tracking ambulances, staff)
23 Transport Blood Analysis Portable, computerbased Capillary/ cartridge samples Immediate results Fine-tune management QA issues at some hospitals
24 Telemedicine & Tele-Echocardiography: Utilization for the Diagnosis and Management of Neonates/Children with Congenital Heart Disease (University of Iowa)
25 Transport to the Cath Lab? Is it Indicated for Neonates? No major studies for efficacy with neonates Congenital heart defects: -TGA no ASD/VSD -Arrhythmias -Uncertain diagnosis
26 Residents on Transport: too little too late? Team Leadership
27 National Organizations: Get Involved Now!!! AAP Section on Transport Medicine ( International Association of flight Paramedics ( Air Medical Physicians Association ( Air and Surface Transport Nurses Association ( National EMS Pilots Association ( National Association of Neonatal Nurses ( Association of Air Medical Services (
28 Guidelines, 3 rd ed. (2007), AAP
29 History: Late 80 s: first publication from the Academy The start of the S.O.T.M. in rd ed represents a collaboration of authors from over 20 specialties Topics that are important for clinicians and administrators alike No other Neonatal (& pediatric) comprehensive resource
30 Contents: Key clinical areas Team configurations Team organization Communications center Quality improvement Reimbursement Ethical considerations Legal issues Research Safety (vehicles & equipment) International transports Integration with EMS Altitude physiology Accreditation Family centered care
31 Billing & Reimbursement: The former is required for the latter but the latter varies regardless of the former
32 The Transport Financial Commandments Budgeting is a key component to a program s organization Budget serves to allocate limited $$ resources among competing users Fixed (salaries, fringe, benefits) v. variable (supplies, maintenance, overtime) costs Delineate revenue: commercial, managed care, Medicaid, etc Unit based v. dedicated v. private team Trainees or full-time members
33 The Transport Financial Commandments: continued Depending on team employees status (team v. hospital employees), highest reimbursement per transport is usually if all charges are billed to pt. and collected by the institution. The institution needs to evaluate whether revenues will support all personnel on team. The value of interfacility agreements!!!
34 Three Major Types of Reimbursable Charges for Neonatal Transport: Current Procedural Terminology (CPT) Documentation is a must!
35 99288 Physician direction of emergency medical services, emergency care or advanced life support used for directing the transport staff from a hospital or facility using 2-way communication NOT billed by time units Can t bill for procedures done by team/ems staff if not present May be submitted in addition to admission/cr. Care codes Documentation includes times of all contacts, orders provided, and/or recommendations/directions provided to the EMS team
36 Physician constant attention of the critically ill newborn/infant Younger than 24 months of age First minutes of face-to-face direct contact Similar to BUT each additional 30 minutes after first 74 minutes. Use in conjunction with X1, x2, x3, etc You Must Document!!! <30 min: use E&M codes
37 Requirements: Direct care (not off floor, parent conversations) < 24 months of age Unstable or critically ill Physician only (CPT terminology) Bundled services CVR monitoring Xrays IV access Ventilator management
38 Unbundled Procedures: UAC/UVC placement Intubation Thoracentesis & chest tubes Surfactant
39 99291 & Used for > 24 months of age Similar to & Time based
40 Common Issues: NNP s can use these codes IF states allow-check with your state & 3 rd party vendors If only RNs, may bill a flat hourly fee for transport personnel, including respiratory therapists May use these codes if same MD/ same unit admits pt. (i.e. then use 99295) May NOT be used for return/retro transports if not critically ill
41 CPT Values: CPT Code RVU $$ (Medicare) per x1
42 Case #1: CPT Codes? 2.6Kg term male with resp level I hosp. Pediatrician calls NICU transport team, Attending neonatologist talks with community pediatrician, gives recommendations, dispatches team. After team arrives, talks with RN/RRT team members, makes recommendations to intubate, place UVC. After NICU, same MD admits pt.
43 Case #2: CPT Codes? 2.6Kg term male with resp level I hosp. Pediatrician calls NICU transport team, Attending neonatologist talks with community pediatrician, gives recommendations, diagnosis of L. Ptx, PPHN. Pt. becomes unstable. ino is a possibility MD sent with team, spends 135 minutes of direct care including face to face sign out at receiving NICU.
44 The Transport Crystal Ball Integrated transport programs --serving regions, less competition, less trainees International links & service Researched analysis of NEW Rx & equipment Techno-transports Get Involved locally and nationally!!
45 Thank You! To Reach Me: Questions/comments
46 Neonatal MRI Compatible Intrahospital Transport Isolette
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