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December 2016 Texas Medicaid Provider Procedures Manual

Medical and Nursing Specialists, Physicians, and Physician Assistants Handbook : 9 Physician : 9.2 Services, Benefits, Limitations, and Prior Authorization : 9.2.44 Newborn Services : 9.2.44.2 Hospital Visits and Routine Care

9.2.44.2
The following procedure codes may be reimbursed for neonatal care and intensive care services:
 
Procedure Code(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.
Hospital discharge
99238
99239
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).
Normal newborn care
Subsequent hospital care
Reimbursable once per day in the hospital and limited to a total of seven days. Restricted to clients who are birth through seven days of age.
If the client is diagnosed with a condition that requires more complex care and/or must stay more than 8 days, the provider must bill subsequent neonatal and pediatric care critical or intensive care (procedure codes 99469, 99478, 99479, or 99480).
If the client is readmitted, the provider must bill an initial hospital E/M admission (procedure code 99221, 99222, 99223, or 99468) and the appropriate code for inpatient neonatal critical care (procedure code 99469).
Newborn admission and discharge, same date
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 once, and only on the day of delivery, when billed by a physician other than the delivering physician.
Newborn resuscitation
Initial hospital care and initial intensive care
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 appropriate procedure code that must 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) must be billed.
* Newborn examinations billed with procedure codes 99460, 99461, and 99463 may be counted as a THSteps periodic medical checkup when all necessary components are completed and documented in the medical record.
** 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).
 
Note:
Refer to:
Section 5, “THSteps Medical” in the Children’s Services Handbook (Vol. 2 Provider Handbooks).
Subsection 5.3.9, “Newborn Examination,” in the Children’s Services Handbook (Vol. 2 Provider Handbooks) for a list of the required components for an initial THSteps exam.
Retrospective review may be performed to ensure documentation supports the medical necessity of the service and any modifier used when billing a claim.
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 a procedure code in Column B:
 
36410, 96361, 99291, 99292, 99307, 99354, 99355, 99356, 99357, 99471, 99472, 99478
36410, 94761, 96361, 99291, 99292, 99307, 99354, 99355, 99356, 99357, 99471, 99472, 99478, 99479
36410, 96361, 99291, 99292, 99307, 99308, 99309, 99310, 99318, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99354, 99355, 99356, 99357, 99471, 99472, 99478, 99479, 99480

Texas Medicaid & Healthcare Partnership
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