AAFP Successfully Argues to Retain CPT Code Edit for Newborn Care

Resubmit or Appeal Denied Claims After Oct. 1

July 26, 2013 04:15 pm News Staff

The Academy recently disagreed with CMS and convinced the agency to reverse itself on modification of a claims-processing edit involving two CPT codes used by family physicians in the provision of care to newborns.

[Stock photo of doctor cradling newborn's head]

Previously, physicians could bill two separate newborn services on the same day -- CPT code 99468 for initial inpatient neonatal critical care and CPT code 99460 for initial hospital or birthing center care for evaluation and management (E/M) of a normal newborn -- by adding a "modifier 25" to the normal newborn code.

In a proposal submitted last spring, CMS sought to negate physicians' ability to apply the modifier and ruled that under no circumstances would CMS pay both codes on the same day.

However, in a June 28 letter to CMS contractor National Correct Coding Initiative (NCCI), Robert Carr, M.D., the AAFP's CPT advisor protested CMS' action.

"I must object," Carr wrote in the letter to NCCI Medical Director Niles Rosen, M.D. "It is not an uncommon scenario for a family physician or pediatrician to provide initial care and ongoing management for a seemingly healthy newborn who then deteriorates many hours later and needs neonatal intensive care services."

Furthermore, said Carr, CPT guidelines in such a situation are very explicit. He quoted a portion of those guidelines directly: "When normal newborn services are provided by the same individual on the same date that the newborn later becomes ill and receives additional intensive or critical care services, report the appropriate E/M codes with the modifier 25 for these services in addition to the normal newborn code."

Carr argued that CMS' proposal -- which took effect on July 1 -- directly contradicted CPT guidance. He urged NCCI and CMS to reconsider their position.

Fast forward to July 11 when the AAFP received confirmation of CMS' pivot on the issue. "CMS has reversed this decision and will once again allow use of NCCI-associated modifiers with this edit," said Rosen, in his response to Carr.

Confirmation of the reversal will be published on Oct. 1 and will be retroactive to July 1.

Some family physicians may need to take action, however. Physicians with claims denials related to the NCCI edit for services provided between July 1 and Sept. 30 should resubmit or appeal the denied claims to their local claims processing contractor on or after Oct. 1, advised Rosen.

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