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HIPAA: NICU/PICU Services Code Conversion

HIPAA-mandated changes to billing requirements for Neonatal and Pediatric Intensive Care Unit (NICU/PICU) services are effective for dates of service on or after June 1, 2019.

Congress passed HIPAA in 1996. In addition to eliminating the use of HCPCS Level III local codes, HIPAA does the following:

  • Provides the ability to transfer and continue health insurance coverage for millions of American workers and their families when they change or lose their jobs;
  • Reduces health care fraud and abuse;
  • Mandates industry-wide standards for health care information on electronic billing and other processes; and
  • Requires the protection and confidential handling of protected health information.

Historically, California has used thousands of HCPCS Level III or local codes (also known as interim codes) for billing and reimbursement of services and supplies. National codes, such as CPT codes are typically more specific in nature compared to local codes. Using HIPAA-compliant CPT national codes:

  • Simplifies the processes and decreases the costs associated with payment for health care services;
  • Improves the efficiency and effectiveness of the health care system and decreases administrative burdens on providers (for example, medical practices, hospitals and health care plans);
  • Provides standardization and consistency in medical service coding; and
  • Characterizes a general administrative situation, rather than a medical condition or service, by using non-clinical or non-medical code sets.

The use of CPT or HCPCS Level II national codes is required to bill for the service visit with the recipient on or after June 1, 2019.

The claim line may consist of one of the following:

  • CPT national code; or
  • CPT national code with modifier(s).

Effective for dates of service on or after June 1, 2019, only CPT national codes are reimbursable for NICU/PICU services.

A NICU is an intensive care unit specializing in the care of ill or premature newborn infants.

A PICU is an area within a hospital specializing in the care of critically ill infants, children, teenagers and those under 21 years of age who meet California Children’s Service (CCS) medical eligibility criteria.

The code conversion billing requirements for NICU/PICU providers (physician and physician groups) include the use of CPT national codes. Complete listings of the approved national codes are available on the NICU/PICU Services Code Conversion Crosswalk located in the NICU/PICU section of the HIPAA: Code Conversions page of the Medi-Cal website. The NICU/PICU Code Conversion Crosswalk is designed with three different levels of criticality and defines codes specific to age, weight and frequency of visits. It is important to follow the NICU/PICU Code Conversion Crosswalk to ensure correct billing and reimbursement. A Service Authorization Request (SAR)/electronic SAR (eSAR) is required to bill the CPT national codes and avoid claim denials.

The following FAQs will provide an overview of the code conversion and point to resources for additional information.

  1. What does the conversion from HCPCS Level III local codes to CPT national codes mean?

    The conversion from HCPCS Level III local codes to the HIPAA-compliant CPT national codes means that NICU/PICU providers who currently submit HCPCS Level III local codes when billing for their services are required to submit claims using specified CPT national codes effective for dates of service on or after June 1, 2019.

  2. Who is affected by the conversion to HIPAA-compliant CPT national codes?

    Approved NICU/PICU CCS providers (physician and physician groups) using the CMS-1500 claim forms, including ANSI 837P transactions for electronic billing and submitting medical claims for NICU/PICU services rendered on or after June 1, 2019, are required to use the HIPAA-compliant CPT national codes identified in the NICU/PICU Code Conversion Crosswalk on the HIPAA: Code Conversions page.

  3. What is an approved NICU or an approved PICU?

    An approved NICU is determined by the CCS program to meet the requirements in order to render services to a CCS client. It is defined as a facility within a CCS-approved pediatric community, general community or special hospital that has the capability of providing a range of neonatal care services according to designated level of care for neonates and infants requiring care beyond that routinely available in a well newborn nursery.

    An approved PICU is determined by the CCS program to meet the requirements in order to render services to a CCS client. It is defined as a unit within a CCS-approved tertiary or pediatric community hospital that has the capability of providing definitive care for a wide range of complex, progressive, rapidly changing, medical, surgical or traumatic conditions, requiring a multidisciplinary approach to care for beneficiaries under 21 years of age who meet CCS medical eligibility criteria.

  4. How do I become an approved CCS provider for NICU/PICU services?

    If you have interest in becoming a CCS provider, visit the California Children's Services page of the California Department of Health Care Services (DHCS) CCS website and refer to Overview of the CCS Medical Eligibility section to view the list of CCS-eligible medical conditions and online CCS Provider Paneling application.

  5. Do I have to bill the codes recommended on the Crosswalk?

    No. The intent of the Crosswalk is to be a general guide only to assist in the seamless transition from HCPCS Level III local codes to HIPAA-compliant CPT national codes. Please adapt to your billing situation.

  6. When does this code conversion take place?

    The code conversion to the HIPAA-compliant CPT national codes for NICU/PICU services is effective for dates of service on or after June 1, 2019.

    Claims billed with HCPCS Level III local codes for dates of service on or after June 1, 2019, are no longer eligible for reimbursement and are denied with Remittance Advice Details (RAD) Code 0362Procedure number billed is not an authorized Medi-Cal procedure code.

  7. How does the conversion impact claims billed with dates of service before and after June 1, 2019?

    Continue to bill with HCPCS Level III local codes for dates of service on or before May 31, 2018.

    Begin billing claims with HIPAA-compliant CPT national codes for dates of service on or after June 1, 2019.

  8. How can I dispute a claim denial?

    Providers have three options for disputing claim denials:

    • Submit a new claim with corrected information if the dates of service are within the six month billing limit;

    • Submit an appeal within 90 days of the date on the RAD showing the claim denial;

    • Submit a Claims Inquiry Form (CIF) within six months of the date on the RAD showing the claim denial.

    For more information, providers should refer to the Claim Submission and Timeliness Overview (claim sub) section of the Part 1 provider manual and the Appeal Form Completion (appeal form) and CIF Completion (cif co) sections of the appropriate Part 2 provider manual.

  9. Are all NICU/PICU codes changing as part of this code conversion?

    No. Most NICU/PICU codes have already converted to CPT national codes and are not affected by this code conversion. If the codes you currently bill are not listed on the NICU/PICU Code Conversion Crosswalk located in the NICU/PICU section of the HIPAA: Code Conversions page then continue billing as you have been.

  10. Which HCPCS Level III local codes are converting to the CPT national codes as part of the NICU/PICU code conversion?

    HCPCS Level III local codes Z0100, Z0102, Z0104, Z0106 and Z0108 are converting to more specific CPT national codes effective June 1, 2019.

  11. How are NICU/PICU CPT national codes more specific?

    NICU/PICU CPT national codes describe specific identifying factors such as a beneficiary's age, weight and level of care as well as identifying initial or subsequent care and the amount of time providing that care.

  12. How are the levels of care described for initial and subsequent NICU/PICU services as of June 1, 2019?

    Critical: Children receiving ventilator support (including continuous positive airway pressure [CPAP]), invasive monitoring and/or intravenous (IV) pharmacological support of the circulatory system.

    Intensive: Cardiorespiratory monitoring for unstable physiology; for example, apnea or hypoglycemia.

    Non-Critical, Non-Intensive: Physiologic stability but requires support such as tube feeding, IV medicines or fluid covered.

  13. What is the difference between initial and subsequent care?

    Initial service codes are reported when a neonate, infant or pediatric beneficiary receives care that is provided on the initial day (first 24 hours or less).

    Subsequent service codes are reported when a neonate, infant or pediatric beneficiary receives care that is provided after the initial day.

  14. What CPT national codes are replacing HCPCS Level III local codes Z0100, Z0102, Z0104, Z0106 and Z0108?

    Initial Inpatient Critical Care; some of these codes have age restrictions.

    • 99291 – Critical care, evaluation and management of the critically ill or critically injured patient; first 30 – 74 minutes.

    • 99292 Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes.

    • 99468 – Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger.

    • 99471 – Initial inpatient pediatric critical care, per day, for evaluation and management of a critically ill infant or young child, 29 days through 24 months of age.

    • 99475 – Initial inpatient pediatric critical care, per day for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age.

    Subsequent Inpatient Critical Care; some of these codes have age restrictions.

    • 99291 – Critical care, evaluation and management of the critically ill or critically injured patient; first 30 – 74 minutes.

    • 99292 – Critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes.

    • 99469 – Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger.

    • 99472 – Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 29 days through 24 months of age.

    • 99476 – Subsequent inpatient pediatric critical care, per day, for the evaluation and management of a critically ill infant or young child, 2 through 5 years of age.

    Initial Intensive Care; some of these codes have an age restriction.

    • 99477 – Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions and other intensive care services.

    Subsequent Intensive Care; these codes have weight restrictions.

    • 99478 – Subsequent intensive care, per day, for the evaluation and management of the recovering very low birth weight infant (present body weight less than 1500 grams).

    • 99479 – Subsequent intensive care, per day, for the evaluation and management of the recovering low birth weight infant (present body weight of 1500–2500 grams).

    • 99480 – Subsequent intensive care, per day, for the evaluation and management of the recovering infant (present body weight of 2501–5000 grams).

    Initial Non-Intensive, Non-Critical Care; these codes have guidelines for key components and time spent at bedside.

    • 99222 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these three (3) key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.
    • Note:

      Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of moderate severity. Typically, 50 minutes are spent at the bedside and on the patient's hospital floor or unit.

    • 99223 – Initial hospital care, per day, for the evaluation and management of a patient, which requires these three (3) key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity.
    • Note:

      Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.

    Subsequent Non-Intensive, Non-Critical Care; these codes have guidelines for key-components and time spent at bedside.

    • 99232 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two (2) of these three (3) key components: an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity.
    • Note:

      Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Typically, 25 minutes are spent at the bedside and on the patient's hospital floor or unit.

    • 99233 – Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least two (2) of these three (3) key components: a detailed interval history; a detailed examination; medical decision making of high complexity.
    • Note:

      Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit.

  15. What codes do I use when billing for initial intensive care service, not critically ill, for beneficiaries over 28 days in age?

    If the beneficiary's age is between 29 days and 21 years, assign the initial hospital care codes 99222 and 99223.

  16. What codes do I use when billing for subsequent intensive care service, not critically ill, for beneficiaries over 11 pounds (5000 grams)?

    If the recipient's weight crosses the 5,000-gram threshold, assign the subsequent hospital care codes 99232 and 99233.

  17. What is a modifier?

    Modifiers supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Modifiers help further describe a procedure code without changing its definition.

    The following modifiers are applicable for dates of service on or after the policy effective date of June 1, 2019:

    • TG (complex/high tech level of care)

    • HA (child/adolescent program)
  18. When would I use the TG and/or HA modifier?

    Modifier TGand/or modifier HA are used when billing CPT national codes 99291and 99292.

    The only instance a modifier is required is for 99291 and 99292 when rendered at an approved NICU/PICU facility.

  19. Can more than one NICU/PICU CPT national code be billed for the same date of service?

    The CPT national codes listed on the NICU/PICU Code Conversion Crosswalk are used to bill for 24 hours of care and only one code is reimbursable for the same recipient and date of service, with the exception of existing CPT national codes 99291 and 99292.

    CPT codes 99291 and 99292 can be billed for the same date of service; however, a medical review is required to verify that the documentation submitted with the claim demonstrates the physician's time being billed was spent evaluating, providing care to and managing a critically ill/injured beneficiary; the critically ill/injured beneficiary received the full attention from the physician; and the physician provided no services to any other beneficiary(s) during the same time period.

    Evaluation and Management (E&M) codes 99291 and 99292 cannot be billed separately by the same provider for the same recipient and date of service.

  20. What is the difference between the existing critical care codes 99291 and 99292?

    CPT national code 99291 is only billable once per day.

    CPT national code 99292 may be billed more than once on the same day of service.

  21. Are there any frequency limitations when billing intensive care services?

    No. Intensive care services are no longer limited to billing once in 180 days for dates of service on or after the policy effective date of June 1, 2019.

  22. Where can I find the rates for reimbursable NICU/PICU CPT national codes?

    Providers may access Medi-Cal Rates under the References tab located on the Medi-Cal website.

  23. Does this code conversion make any changes or impact the Affordable Care Act (ACA) and CCS-enhanced payments?

    The NICU/PICU code conversion does not make any changes or impact the Affordable Care Act-(ACA) or CCS-enhanced payments.

  24. What is the “block billing (split claims)/from-through” billing method?

    “Block billing (split claims)”, also known as “from-through” billing, is a method of billing that allows providers to bill for the same service rendered on different dates of service, without having to complete a separate claim line for each date of service.

    Providers should refer to the CMS-1500 Special Billing Instructions (cms spec) section of the Part 2 provider manual for additional information and a billing example of “from-through” billing.

  25. Is “block billing/from-through” billing allowed for NICU/PICU physician services?

    With the exception of prolonged inpatient E&M services code 99292, NICU/PICU providers (physician and physician groups) may use this billing method.

    Split billing into separate claims for dates of service on or before May 31, 2019, containing HCPCS Level III local codes and for dates of service on or after June 1, 2019, containing HIPAA-compliant CPT national codes.

  26. What are CCS SCGs?

    Service Code Groupings (SCGs) are a group of procedure codes authorized to a CCS-approved provider for the provision of a group of related health care services that are authorized through the SAR/eSAR process. A SCG SAR enables the provider to render care to a CCS client without obtaining repeated procedure-specific SARs/eSARs.

  27. What CCS SCGs are used for NICU/PICU providers (physician & physician groups)?

    NICU/PICU providers (physician and physician groups) SCGs are 01, 02, 03 and 07.

    No changes will be made to the current SCG assignments for existing CPT national codes 99291, 99292 and 99477. All new CPT national codes listed on the NICU/PICU Code Conversion Crosswalk belong to SCG 02.

    For a list of codes associated with each of the SCGs, refer to the California Children's Services (CCS) Program Service Code Groupings (cal child ser) section of the Part 2 provider manual.

  28. How does this conversion impact my SARs/eSARs?

    Effective for dates of service on or after June 1, 2019, NICU/PICU providers may no longer submit SARs/eSARs with HCPCS Level III local codes. All SARs submitted for NICU/PICU SCG 01, 02, 03 and 07 must be submitted with the appropriate CPT national codes.

    No changes will be made to the current SCG assignments for the existing national CPT national codes 99291, 99292 and 99477. All-new national CPT national codes listed on the NICU/PICU Code Conversion Crosswalk belong to SCG 02.

    Providers must request existing SARs with the HCPCS Level III local codes be end-dated effective June 1, 2019 and submit a new SAR with the appropriate CPT national code(s) to cover any remaining service period on or after the policy effective date of June 1, 2019.

    Claims billed with HIPAA-compliant CPT national codes prior to the policy effective date of June 1, 2019, or claims billed with HCPCS Level III local codes on or after the policy effective date of June 1, 2019, are denied with Remittance Advice Details (RAD) Code 9662: Service authorization status not active.

  29. Do I need to update my billing software?

    Updates may be needed. Providers are recommended to inquire with their vendors and billing/system contractors to determine if any software changes are needed and make the necessary changes where applicable.

  30. How do I test/validate that my system changes are compatible with the code conversion?

    Submitters may test status to ensure accurate file format, completeness and validity for HIPAA‑compliant claims transactions by logging into the Medi-Cal test site using their submitter ID and password. Instructions for Computer Media Claims (CMC) testing can be found in the Testing and Activation Procedures section of the CMC Billing and Technical Manual.

  31. Where can I find additional information related to the NICU/PICU conversion from HCPCS Level III local codes to HIPAA-compliant CPT national codes?

    For additional information, providers may:

  32. Who can I contact if I have additional questions or concerns?

    Providers may request additional onsite or telephone support via the Telephone Service Center (TSC) at 1-800-541-5555, from 8 a.m. to 5 p.m., Monday through Friday, except holidays. Border providers and out-of-state billers billing for in-state providers call (916) 636-1200. Providers calling from outside of California call the Out-of-State Provider Unit at (916) 636-1960.

    For electronic claim submission questions, providers contact the TSC at 1-800-541-5555, select option 4 for the Technical Help Desk and option 2 for CMC.

    All other questions about the NICU/PICU claims conversion may be submitted via email to CAMMISCodeConversion@conduent.com.