If you're about to refund critical and intensive care payments because your pediatricians or neonatologists weren't on the premises around the clock on billed days, there's evidence that your charges are correct.
You're going to have to defend your claims for 99295-99296 (Inpatient neonatal critical care) and 99298-99300 (Continuing intensive care services) in light of carriers' misunderstandings of the term "direct supervision." "Usually when a service or procedure requires direct physician supervision, it means the physician must be immediately available and at the facility throughout the service or procedure," says Richard H. Tuck, MD, FAAP, a nationally recognized speaker on pediatric coding and pediatrician at PrimeCare of Southeastern Ohio.
But this isn't the case for neonatal critical care and subsequent intensive care codes. Before you issue refund checks, prepare to explain the nuances of 99295-99300 to payers with these tips. Prepare to Fight Medicaid's Refund Demand -- Here's How One Pediatric Coding Alert subscriber reached out for help when a carrier challenged her use of 99298 (Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant [present body weight less than 1500 g]). Medicaid asked the pediatrician to refund 99298 because he was not physically in the hospital around the clock.
Reason: The CPT coding book indicates 99295-99300 require "Constant observation by the healthcare team under direct physician supervision." But this doesn't mean the on-call neonatologist has to be physically in the hospital throughout the 24-hour care of the infant, says Richard A. Molteni, MD, FAAP, a neonatologist and vice president and medical director of Children's Hospital and Regional Medical Center in Seattle. "In this situation 'direct supervision' does not imply physical presence," he says.
Instead: The attending physician must constantly supervise the neonatal team, which may include a resident, neonatal nurse practitioner, fellow, bedside registered nurse, and respiratory therapist. "But this [supervision] can be from off-site," Molteni says. The attending physician must provide direct patient contact and be readily available.
Translation: The doctor doesn't have to do the procedures or provide 24-hour in-house coverage. But he needs to be physically present at some time during that 24-hour period to examine the patient and review the patient's care with the healthcare team, according to CPT Assistant's August 2000 guidelines for direct physician supervision of neonatal intensive care. Let Your MDs Get Some Shut-Eye Before you think of making your neonatologists stay at the hospital, let providers know that this is not a requirement of 99295-99300 services. "Only about 50 percent of NICU's have 24-hour in-house neonatology," Molteni says.
The neonatologists may leave the hospital if they are present to perform multiple rounds of care during the day [...]