TMPPM 2010 > Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook > Physician > Procedures and Services > Newborn Services > Hospital Visits and Routine Care

   
 

6.3.38.5 Hospital Visits and Routine Care

The following procedure codes may be reimbursed for neonatal care and intensive care services:

Service
Procedure Code(s)
Benefit(s) and Limitation(s)

Initial hospital E/M admission

99221
99222
99223

If the client is readmitted within the first 28 days of life, the provider must bill an initial hospital evaluation and management (E/M) admission.

Reimbursed one per day, any provider.

Procedure codes 99478, 99479, and 99480 must be billed for subsequent neonatal intensive (noncritical) services. The present body weight of the neonate or infant determines the procedure code that should be billed. When the present body weight of a neonate exceeds 5,000 grams, a subsequent hospital care service (procedure code 99231, 99232, or 99233) should be used.

Hospital discharge

99238
99239

Reimbursed for the client's discharge from the hospital.

Subsequent hospital and hospital consultation services

99251
99252
99253
99254
99255

Services for a client who is not critically ill and unstable but who happens to be in a critical care unit must be reported using subsequent hospital codes (99478, 99479, and 99480) or hospital consultation codes (99251, 99252, 99253, 99254, and 99255).

Initial newborn care

99460*

May be reimbursed once per lifetime, any provider.

May be reimbursed when billed with a well newborn diagnosis code.

Normal newborn care

99461*

May be reimbursed once per lifetime, any provider.

Subsequent visits must be billed using an appropriate visit code based on the place of service.

May be reimbursed when billed with a well newborn diagnosis code.

Subsequent hospital care

99462

Reimbursable once per day in the hospital.

Subsequent hospital care (procedure code 99462) is reimbursable once per day in the hospital. Procedure code 99462 is not reimbursable in the birthing center.

May be reimbursed when billed with a well newborn diagnosis code.

Newborn admission and discharge, same date

99463**

May be reimbursed once per lifetime when submitted by any provider.

Reimbursed for newborns who are admitted and discharged on the same day from the hospital or birthing room setting (either hospital or birthing center).

May be reimbursed when billed with a well newborn diagnosis code.

Attendance at delivery

99464

May be reimbursed once, and only on the day of delivery, when billed by a physician other than the delivering physician.

Newborn resuscitation

99465

Reimbursed for the resuscitation of the newborn.

Initial hospital care and initial intensive care

99477

Reimbursed for those neonates who require intensive observation, frequent interventions, and other intensive services.

Non-time-based procedure codes must be billed daily irrespective of the time that the provider spends with the neonate or infant.

Initial neonatal critical and intensive care (procedure codes 99468 and 99477) may be reimbursed once per admission, any provider.

Note: For subsequent admissions during the first 28 days of life, procedure codes 99468 and 99477 may be considered for reimbursement upon appeal.

Subsequent intensive care

99478
99479
99480

Non-time-based procedure codes must be billed daily irrespective of the time that the provider spends with the neonate or infant.

Subsequent critical and intensive care (procedure codes 99469, 99478, 99479, and 99480) will be considered for reimbursement once per day, any provider.

Services for a client who is not critically ill and unstable but who happens to be in a critical care unit must be reported using subsequent hospital codes (99478, 99479, and 99480) or hospital consultation codes (99251, 99252, 99253, 99254, and 99255).

Procedure codes 99478, 99479, and 99480 must be billed for subsequent neonatal intensive (noncritical) services. The present body weight of the neonate or infant determines the procedure code that should be billed. When the present body weight of a neonate exceeds 5,000 grams, a subsequent hospital care service (procedure code 99231, 99232, or 99233) should be used.

* Newborn examinations billed with procedure codes 99460 and 99461 may be counted as a THSteps periodic medical checkup when all necessary components are completed and documented in the medical record.
If a brief newborn examination is performed that does not fulfill periodic checkup criteria, procedure code 99460 or 99461 may be reimbursed with modifier 52.
** If the client is readmitted within the first 28 days of life, the provider must bill an initial hospital evaluation and management (E/M) admission (procedure code 99221, 99222, or 99223).

Refer to: Subsection 6.3.1.8, "Newborn Examination" in the Children's Services Handbook (Vol. 2 Provider Handbooks) for a list of the required components for an initial THSteps exam.

Section 6, "THSteps Medical" in the Children's Services Handbook (Vol. 2 Provider Handbooks).

Retrospective review may be performed to ensure documentation supports the medical necessity of the service and any modifier used when billing a claim.

Procedure codes 99460, 99461, 99462, and 99463 may be reimbursed when billed with one of the following well newborn diagnosis codes:

Diagnosis Codes

V290

V291

V292

V293

V298

V299

V3000

V3001

V301

V302

V3100

V3101

V311

V312

V3200

V3201

V321

V322

V3300

V3301

V331

V332

V3400

V3401

V341

V342

V3500

V3501

V351

V352

V3600

V3601

V361

V362

V3700

V3701

V371

V372

V3900

V3901

V391

In the following table procedure codes in Column A will be denied when billed with the same date of service by the same provider as procedure codes in Column B:

Column A (Denied)
Column B

99462

99460, 99461

99238, 99239

99460, 99461, 99463

99462

99238, 99239

99469

99468, 99477

99356, 99357

99468, 99469, 99477

99478, 99479, 99480

99471, 99472, 99475, 99476

The following procedure codes will be denied when billed on the same day, by the same provider as procedure codes 99460, 99461, and 99462:

Procedure Codes

G0102

43752

93040

93041

93042

94002

94003

95831

95832

95833

95834

95851

95852

96523

97802

97803

The following procedure codes will be denied when billed on the same day, by the same provider as procedure code 99463:

Procedure Codes

G0102

43752

94002

94003

95831

95832

95833

95834

95851

95852

96523

97802

97803

99460

99461

99462

The following procedure codes will be denied when billed with the same date of service by the same provider as procedure code 99464:

Procedure Codes

G0102

43752

94002

94003

95831

95832

95833

95834

95851

95852

96523

97802

97803

Modifier 25 may be used to identify a significant separately-identifiable E/M service performed by the same physician on the same day as the procedure or other service. When billing with modifier 25, the provider must provide documentation to substantiate the use of the modifier in order for services to be considered for reimbursement. Documentation includes, but is not limited to, office or hospital medical records, such as history and physical progress notes, and lab results, if applicable.

The following procedure codes will be denied when billed with the same date of service by the same provider as procedure code 99465:

Procedure Codes

G0102

43752

94002

94003

95831

95832

95833

95834

95851

95852

96523

97802

97803

99464

The following procedure codes will be denied when billed with procedure codes 99468, 99469, 99477, 99478, 99479, and 99480:

Procedure Codes

G0102

M0064

31500

36000

36140

36400

36405

36406

36410

36420

36430

36440

36510

36555

36568

36591

36600

36620

36660

43752

51100

51701

51702

62270

71010

71015

71020

90847

90862

90940

91105

92002

92004

92012

92014

93040

93041

93042

93561

93562

94002

94003

94375

94760

94761

95831

95832

95833

95834

95851

95852

96360

96361

96523

97802

97803

99201

99202

99203

99204

99205

99211

99212

99213

99214

99215

99217

99218

99219

99220

99221

99222

99223

99231

99232

99233

99234

99235

99236

99238

99239

99241

99242

99243

99244

99245

99251

99252

99253

99254

99255

99281

99282

99283

99284

99285

99291

99292

99471*

99472*

99478*

99479*

99480**

99307**

99308**

99309**

99310**

99315

99316

99318**

99324**

99325**

99326**

99327**

99328**

99334**

99335**

99336**

99337**

99341

99342

99343

99344

99345

99347

99348

99349

99350

99354*

99355*

99356*

99357*

99460

99461

99462

99463

*Procedure codes are not bundled with procedure codes 99478, 99479, and 99480.
** Procedure codes are not bundled with procedure code 99480.


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