Prepare for the unexpected when the patient is expecting.
Oh, those cute little babies! All those fingers and toes and noses — when I grow up, I want to be one of those volunteers in nurseries who just sits and rocks babies all day. It sure beats this crazy coding world I’ve gotten myself into. Wouldn’t you rather sing rock-a-bye baby, watch them while they sleep, pace the floor when they cry, change their diaper, feed them, walk the floor again … I may be rethinking this whole idea.
Babies can be a handful for sure. Even the healthiest baby requires lots of hands-on attention during the delivery process. From the moment of birth, the baby is evaluated and, after a moment with the mother, is usually handed to a nurse or other skilled attendant to assess the baby’s condition. They may use the common Apgar system (Appearance, Pulse, Grimace, Activity, Respiration) — in use since the early 1950s. High Apgar scores indicate a healthy newborn.
Sometimes the obstetric provider has an indication of a possible issue prior to the delivery. Perhaps there is meconium (the first feces of a fetus or infant) in the amniotic fluid or the fetus’ heart rate in utero is low. The obstetrician (OB) needs to take care of the mother, so they will call in a pediatric provider to care for the baby.
There are a few different codes the pediatric provider can use, and they basically depend on the place of service and the condition of the newborn. There are critical care codes that can be used for the newborn if applicable, but what we want to talk about now are the two codes used for attendance at delivery (AAD) and resuscitation.
Attendance at Delivery
CPT® code 99464 Attendance at delivery (when requested by the delivering physician or other qualified health care professional) and initial stabilization of newborn means the provider is at the delivery, physically present in the delivery room with hands out, waiting for the baby.
The American Academy of Pediatrics states that if the provider misses the delivery by even a few seconds they cannot code 99464. In that case, they need to choose either initial neonatal care or one of the critical care codes, whichever is applicable. Providers must document that they were in the room at the exact time the baby was born to use 99464.
The other key point of this code is that the pediatric provider must be requested by a physician or other qualified healthcare professional. We can reasonably assume the OB is not going to stop delivering the baby to pick up the phone and page the on-call pediatric provider; the OB will tell the other staff in the room to do it. The documentation needs to support that the OB requested the page.
Of course, we must have medical necessity for AAD. If the hospital mandates that a pediatrician is in the delivery room for all or certain types of deliveries, such as C-sections, this is not deemed medically necessary. The key is that newborn distress is expected, so another person needs to be in the room to take the baby immediately after birth.
AAD includes stabilization of the newborn. Stabilization includes:
- Initial drying
- Visual inspection
- Discussion with OB and/or parents
Delivery/Birthing Room Resuscitation
In contrast, code 99465 Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output is for resuscitation. The description demands that positive pressure ventilation (PPV) or cardiopulmonary resuscitation (CPR) be performed to use this code.
- Bag and mask
- Ventilation (not just CPAP)
The newborn must be in some sort of distress such as acute inadequate ventilation or cardiac output. Documentation should state acute respiratory distress or failure, or other cardiopulmonary distress. The provider must perform some type of emergency measure to restore breathing and heart function.
Both AAD and resuscitation can be billed with initial newborn care (99460), initial neonatal critical care (99468), and initial intensive neonate care (99477). Code 99465 can be billed with standby (99360), intubation and central line codes, and other
necessary procedures, as long as they are not performed as a convenience before admission to the NICU.
AAD and resuscitation on the same day cannot be billed together. If the provider is in attendance and then performs resuscitation, only bill the 99465, since it has the higher relative value units (RVUs).
AAD vs. Resuscitation
Proper coding requires proper documentation. When deciding which code to bill, look for the documentation to state whether the newborn is in distress. If not, attendance at delivery is likely your best choice, as long as the provider is in the room at delivery. If the baby is in distress, look for documentation of PPV or CPR, and bill the resuscitation code.
Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, is coding team leader at MedKoder in Hannibal, Mo. She has more than 15 years of experience in multiple areas of healthcare including auditing and compliance. Cox has been certified since 2002 and is treasurer of the Quincy, Ill./Hannibal, Mo., local chapter. She is the Region 5 AAPC National Advisory Board representative.