Coding and Reimbursement: Principles and Practices



Coding and Reimbursement


Principles and Practices


Gilbert I. Martin, Richard Molteni and Stephen A. Pearlman


Neonatology as a relatively new specialty of pediatric care has developed its own national coding definitions and guidelines that dictate how neonatal specialists are reimbursed. Payment in the early years followed the basic “fee for service” principles that based payments on regional averages (usual and customary), but in time, other methods of payment that were resource-based and nationally accepted were introduced. Like other medical specialties, payment pressures required physicians to learn the “business” of neonatology. During training, most physicians were not exposed to this aspect of neonatal care. Previously it was taught that to practice medicine was a privilege, and if one worked diligently the financial considerations and rewards would automatically follow. Instead more complex billing rules led to the need for neonatal business office professionals to keep a practice fiscally viable. The guidelines of reimbursement are convoluted, and more intense government and insurer oversight made careful documentation and adherence to coding rules essential.


In this chapter, the following questions will be addressed as they apply to newborn care. How do I code for my time? How do I code for a procedure? Will I be reimbursed for the extra time and effort I spend caring for the patient? Medical coding in the United States uses three major coding systems: Current Procedural Terminology (CPT), the International Classification of Diseases (ICD), and the Healthcare Common Procedure Coding System (HCPCS). The CPT system is a copyrighted product of the AMA, with participation of all major specialties, including pediatrics.3 The CPT contains three categories of codes. Category I codes are five-number codes that represent all services provided to patients. These codes have work values assigned to each service and upon which payers base their reimbursement; Category II codes represent quality indicators and evidenced-based preventive services that do not have direct reimbursement to the codes, but can be used by insurers to base pay for performance to providers; Category III codes, or tracking codes, are assigned to services that are considered experimental and whose universal applicability or scientific validity has yet to be established. Category I codes are divided in CPT into chapters based upon organ systems, unique medical services, or nonprocedural Evaluation and Management (E/M) codes. To understand the complexities of the business of neonatology, we will look to the past, evaluate the present, and consider the future. The included references and monographs will assist the readers to further understand the complexities of CPT coding and reimbursement. The authors suggest that these materials be readily available to every neonatologist and billing office. Those essential references include: CPT 2014; Coding for Pediatrics 2014; Quick Reference Guide to Neonatal Coding and Documentation; ICD-9; ICD-10; Coding With Modifiers; CPT Changes 2014, Pediatric Code Crosswalk: ICD-9-CM to ICD-10-CM; CPT Assistant (AMA-published monthly); and the American Academy of Pediatrics Coding Newsletter.2,3,6


Every reported physician service must also include a patient diagnosis or symptom for which the service was provided. The second coding system, the ICD system, is a listing of diagnostic codes that must accompany and synchronize with the CPT codes used to bill for a service. The ICD codes are discussed later in the chapter. The HPCPS CMS assigned codes will not be reviewed but are available on the following government website: http://www.cms.gov/Medicare/Coding/MedHCPCSGenInfo.



The Basis of Neonatal Coding and Reimbursement


When neonatology emerged as a subspecialty, fees were initially chosen and based on a system of customary, prevailing, and reasonable charges (CPR). The definition of customary charges was the median of an individual’s charges for a particular service, for a defined period of time. The prevailing charge was set at the 90th percentile of the customary charge in a defined payment area. The reasonable charge was the lowest of the physician’s actual fee for that service. In the late 1980s, the AAP developed the first global code set for reporting daily services provided to normal and sick newborns. Procedures were reported separately, and all interventions provided by neonatologists could be reported in addition to these global daily codes. Unbundled procedures concerned payers as additional reintubations, replacement of umbilical lines, and repeated arterial punctures, although necessary, could lead to increasingly higher daily charges. When a system of fixed reimbursement values termed relative value units (RVUs) was assigned to these codes in 1990, a massive shift in reimbursement occurred. This new system (RBRVS) is discussed in detail later in the chapter.


In 1997, the Perinatal Section of the American Academy of Pediatrics established the Perinatal Coding Committee as a subcommittee under its Committee on Coding and Nomenclature (COCN). Although many neonatal codes were part of the Evaluation and Management Section (E/M Inpatient Neonatal and Pediatric Codes), the committee believed there was a need to develop other global codes for critical and intensive neonatal and pediatric patients. A Pediatric/Neonatal toolkit was first published in 2008, and the Quick Reference Guide to Neonatal Coding and Documentation was produced in 2010. It was evident that as the scope of neonatology expanded, additional diagnostic codes were necessary, and ICD-9 was expanded (see later discussion on the ICD system). Most public and private payers have adopted the coding guidelines and rules used by the Center for Medicare and Medicaid Services (CMS) to reimburse services billed to their agency. Most neonatal practices today have developed a “super-bill” for reporting physician services and associated diagnoses. Most also employ a professional billing staff to ensure that coding rules are followed and to follow up on reimbursements and appeals as necessary. Neonatologists understand the importance of their own coding knowledge and their active participation in the coding process. A need for further diagnostic specificity has guided the international introduction of ICD-10 and is being further updated in ICD-11.



Current Procedural Terminology Coding for Neonatology: The Process


A suggestion for a new code or revision of a code can be made by any individual, group, or organization. This suggestion is submitted to the individual’s specialty organization or can be submitted directly to the AMA CPT staff. Once accepted for consideration, the code is sent to the specialty society advisors for review and recommendation to the CPT Editorial Board. Typically, members of the Perinatal Section Coding Committee will present the code to the AAP’s COCN and from there to the CPT’s Editorial Panel. If approved, the code is next reviewed by the AMA/Specialty Society Relative Value Scale Update Committee (RUC). The code is surveyed among physicians in the relevant specialty to establish a suggested value of the physician work component of the code. The results of the survey are then presented to the RUC (the advisors present the codes; the Section is present to support the codes). The RUC decides upon a final value that is then submitted to the Centers for Medicare and Medicaid Services (CMS). The CMS can accept the RUC value or publish a lower value if they disagree with the RUC valuation. They review these recommendations and assign a physician expense and malpractice expense as part of the physician fee schedule. This information is published in the Federal Register in November each year. A 60-day comment period ensues, and if no comments are received, the value becomes final. This is an arduous, complex process that often takes several years for a code to be accepted, valued, and published in CPT. Following publication, neonatologists and their billing offices throughout the United States may report these new codes to all insurers.



Specific Neonatal Codes


Most neonatal codes are per diem or global codes reported only once per day, with the majority of procedures included or “bundled” into the codes. This is a unique code set, and in fact there is a designated section in CPT 2014 dedicated to these neonatal codes. The neonatal codes do not follow the common documentation guidelines required of other Evaluation and Management (E/M) services.


This chapter section will present common neonatal codes in the chronologic order that a health care provider will use them when caring for a neonate and/or family. General coding rules apply and are noted in the following.



1. Documentation must support the selected code, and inpatient location, birth weight, payer, gestational age, and diagnosis do not independently determine the actual code or level of service. There are compliance programs available that educate health care providers in reporting and documentation.


2. Attending physicians working with residents and/or fellows must adhere to the Physician at Teaching Hospitals (PATH) guidelines. This requires an attestation that they have reviewed the resident and/or fellow’s note, have been present for the critical portion of the physical examination or service, and/or completed their own focus exam and are actively involved with the medical decision making process.


3. Health care providers and/or their billing offices must be conversant with both CPT and ICD-10 to match the diagnosis with the level of service provided. If there are questions regarding the relationship between the two types of codes, there can be delays and/or denial of payment.


4. If two or more physicians who are in the same specialty or group using the same billing number see the same patient on the same date, only one encounter is reported and recognized by CPT. If the physicians are in different groups and see the same patient on the same date, two codes can be reported.


5. Many procedures are bundled into the critical and intensive care codes (Table 8-1). This means that they are included within the code and may not be billed separately. An exception is made if these procedures are performed in the delivery room as part of the resuscitation process.



TABLE 8-1


Neonatal and Pediatric Critical Care Bundled Services


















































































































































































Procedures CPT Codes Hourly Critical Care 99291, 99292 Neonatal/Pediatric Transport
99466, 99467		 Neonatal/Pediatric Critical Care 99468, 99469,
99471, 99472
Intensive Care
99477 to 99480
Invasive, Noninvasive Electronic Monitoring
Cardiac output measurements 93561, 93562 X X X
Chest x-rays 71010, 71015, 71020 X X X
Information/data stored in computers, ECG, BP, hematologic data 99090 X X X
Oral or nasogastric intubation 43752, 43753 X X X
Temporary transcutaneous pacing 92953 X X X
Endotracheal intubation 31500 X X X
Ventilatory management CPAP 94002-94003 X X X
94004 X   X
94660, 94662 X X X
Surfactant administration 94610     X
Vascular Access Procedures
Central, peripheral catheterization 36555     X
Umbilical catheterization 36510, 36660     X
Other arterial catheterization 36140, 36620     X
Vascular access procedures 36000 X X X
36400   X X
36405, 36406   X X
36410 X   X
36415, 36591 X X X
Vascular punctures 36420     X
36600 X X X
Intravenous fluid administration 90760, 90761     X
Transfusion blood components 36430, 36440     X
Other Procedures
Pulse oximetry 94760 to 94762 X X X
Pulmonary function testing 94375     X
Lumbar puncture 62270     X
Suprapubic bladder aspiration 51100     X
Bladder catheterization 51701, 51702     X
Car seat testing 99480, 94781     X

Related posts:

  1. Legal Issues in Neonatal-Perinatal Medicine
  2. Gastroesophageal Reflux and Gastroesophageal Reflux Disease in the Neonate
  3. Neonatal Apnea and the Foundation of Respiratory Control
  4. White Matter Damage and Encephalopathy of Prematurity

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Jun 6, 2017 | Posted by in PEDIATRICS | Comments Off on Coding and Reimbursement: Principles and Practices

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