TMPPM 2007 >36.3.5.3 Neonatal Critical Care

Procedure codes 1-99298, 1-99299, and 1-99300 must be used when submitting services for those infants who are low birth weight, very low birth weight, or normal weight and who continue to require intensive observation, frequent services and interventions only available in the intensive care setting even though they no longer meet the definition of critically ill.

Procedure codes 1-99298, 1-99299, or 1-99300 should be submitted for subsequent neonatal intensive (non critical) low birth weight services care per day, irrespective of the time that the physician spends with the neonate or infant as appropriate for the present body weight and intensity of service required by the neonate or infant.

Neonatal critical care is the comprehensive care of the critically ill neonate. Neonatal critical care procedure codes (1-99295 and 1-99296) are comprehensive per diem (daily) care procedure codes for providers personally delivering or supervising the delivery of care of the critically ill neonate as an inpatient.

Refer to: "Critical Care" for references to outpatient critical care services for neonatal, pediatric, and adult patients.

The following procedure codes for subsequent hospital visits and neonatal critical care services are limited to one per day, any provider:

Procedure code 1-99295 should be submitted for the initial day of neonatal critical care irrespective of the time that the physician spends with the critically ill neonate or infant that is 28 days of age or younger.

Procedure code 1-99295 may be considered for reimbursement once per lifetime per critically ill neonate.

Procedure code 1-99296 should be submitted for subsequent neonatal critical care, irrespective of the time that the physician spends with the critically ill neonate or infant that is 28 days of age or younger. Procedure code 1-99296 may be considered for reimbursement once per day, per critically ill neonate (any provider) and is denied when submitted with the same date of service as 1-99295.

Procedure codes 1-99295 and 1-99296 may be used only during the period of time the neonate is considered critically ill. When the neonate is no longer considered critically ill, the E/M procedure codes for subsequent hospital care (1-99231, 1-99232, 1-99233) may be used.

Neonatal critical care and low birth weight services are inpatient, per day charges and only allowed once a day (same provider). No other inpatient E/M services will be considered for reimbursement with the same date of service when submitted by the same provider.

Separate charges for any of the following procedures submitted with the same date of service as neonatal intensive care (procedure codes 1-99295 and 1-99296) and intensive (non-critical) low birth weight services subsequent intensive care (procedure codes 1-99298, 1-99299, and 1-99300) are denied as part of another procedure:


Procedure Codes
2-31500	2-31502	2-36000
2-36400	2-36405	2-36406
2-36410	2-36415	2-36420
2-36430	2-36440	2-36510
2-36540	2-36555	2-36600
2-36620	2-36625	2-36640
2-36660	2-43752	2-51000
2-51005	2-51010	2-51701
2-51702	2-62270	2-62272
4/I/T-71010	4/I/T-71015	4/I/T-71020
1-90760	1-90761	1-90765
1-90766	1-91105	1-92953
5/I/T-93561	5/I/T-93562	1-94002
1-94003	5/I/T-94375	1-94640
1-94642	1-94644	1-94645
1-94660	1-94662	5-94760
5-94761	5-94762	1-99090

The following procedures, when submitted with the same date of service by the same provider, may be considered for reimbursement at the full rate in addition to neonatal intensive care (this is not an all inclusive list):

The same provider may request reimbursement for no more than 28 days. After the 28th day, providers must submit pediatric critical care codes 1-99293 and 1-99294.

Pediatric critical care procedure codes 1-99293 and 1-99294 will be denied when billed by any provider with the same date of service as neonatal intensive or critical care procedure codes 1-99295, 1-99296, 1-99298, 1-99299, and 1-99300.

When critical care services are provided to a neonatal, pediatric, or adult patient in an outpatient setting (e.g., emergency room) and do not result in admission, the critical care should be submitted using procedure codes 1-99291 and 1-99292.

Refer to: "Critical Care" for references to outpatient critical care services for neonatal, pediatric, and adult patients.

Services for a patient who is not critically ill and unstable but who happens to be in a critical care unit must be reported using subsequent hospital procedure codes or hospital consultation procedure codes.

Prolonged service procedure codes 1-99356 and 1-99357 are denied when submitted in addition to initial or subsequent neonatal critical care service (procedure codes 1-99295 and 1-99296).

Prolonged services are denied when submitted with the same date of service and by the same provider as low birth weight and very low birth weight subsequent intensive care procedure codes (1-99298, 1-99299, and 1-99300).

Hospital discharge (procedure codes 1-99238 and 1-99239) are denied when submitted with the same date of service by the same provider as newborn care (procedure codes 1-99431, 1-99432, 1-99433, 1-99435, 1-99298, 1-99299, and 1-99300).

Newborn care procedure codes (1-99431, 1-99432, 1-99433, and 1-99435) and hospital discharge procedure codes (1-99238 and 1-99239) are denied when submitted with the same date of service as critical care procedure codes (1-99295 and 1-99296).

If a hospital discharge is submitted with the same date of service as inpatient neonatal or pediatric critical care, the hospital discharge is denied and the critical care is considered for reimbursement.