Avoid Under-Billing Neonatal Services

Under-reporting medical billing claims is unfortunately common and it costs revenue as you’re not being fully reimbursed for services rendered. Learning the exceptions to the bundles will allow you to break out services that can be billed alone – once you start investigating neonatal services you’ll realize quickly that you may have very been missing legitimate reimbursements.

A scenario that isn’t uncommon is when a doctor attends a delivery of a 28-week gestation baby. The infant received positive pressure ventilation (PPV) in the delivery room (DR) with mask and bag for absent respiratory effort at birth. The baby was then intubated in the delivery room and received PPV on transfer to the neonatal intensive care unit (NICU) where mechanical ventilation was initiated.

Three steps will clear the way for you to choose the best way to report this procedure. Number one, in most cases you will bill 99436/99440 Separately From 99295. When coding resuscitation with initial neonatal critical care, you should always remember one rule: Newborn resuscitation services (99440) may be reported in addition to 99295. In a nutshell, that means, in the above scenario, as well as anytime a pediatrician attends a delivery and provides resuscitation, you should report both 99440 and 99295.

Next, make sure that you code the necessary preadmit procedures. You will want to address whether or not normal resuscitation procedures such as endotracheal intubation (31500, Intubation, endotracheal, emergency procedure). But these bundles reflect inpatient services performed as part of critical care management. This will be a bundled service unless these services were medically necessary in the delivery room prior to admission, the procedures are exempt from the bundle. “The initial-day neonatal critical care code (99295) can be used in addition to codes 99360, 99436, or 99440 as appropriate, when the physician is present for the delivery (99360 or 99436) and newborn resuscitation (99440) is required,” states the AMA in the introductory notes to the “Inpatient Neonatal and Pediatric Critical Care Services” subsection.

The third part of deciding whether to bundle this claim or not will be your use of modifier 59. You may report medically necessary delivery-room procedures in addition to inpatient critical care services because the care occurs at different sites of service. That’s what makes preadmission procedures distinct procedural services from inpatient critical care. If you want to indicate the pediatrician performs the intubation at a separate site from the critical care, you should append modifier 59 (Distinct procedural service) to the delivery-room procedure: 31500-59.

Check with the carrier before you file modifier 59, some carriers want these CPT codes with out modifiers while other require it as part of the medical billing claim.

View all Articles by: Melissa Clark, CCS-P