Guest post: Documentation, billing, and coding bronchopulmonary dysplasia
by Shabih Manzar, MD
Bronchopulmonary dysplasia (BPD) is a disease that affects infants who were born prematurely. The incidence of the condition is inversely proportional to the gestation age of the infant. It is a multifactorial disease that remains poorly understood and inadequately defined. (For more information, see this article on the topic from the June 2018 edition of The Journal of Pediatrics.)
According to a June 2020 article in the American Journal of Respiratory and Critical Care Medicine, the variation in the management depends upon the three phenotypic disease components:
- Moderate-severe parenchymal disease
- Pulmonary hypertension
- Large airway disease
The variation in the treatment, without effecting the BPD outcome, may affect the billing code and ultimately reimbursement for the hospital and physicians. Let’s compare two neonatal intensive care unit (NICU) attendings managing a preterm infant with BPD. One attending preferred high flow and low oxygen, while other preferred low flow and high oxygen.
The patient is a 70-day old preterm infant. He was born at 27 weeks and is now 37 weeks post menstrual age. His current weight is 2540 grams and he is still receiving supplemental oxygen. The effective FiO2 (the presumed amount of oxygen delivered to the alveoli) is calculated per Benaron and Benitz formula. Both attendings followed the higher oxygen saturation target per recommendation.
As seen in the table below, despite receiving different supplemental oxygen, the effective FiO2 is almost the same. In both the management plan, the infant qualifies to have moderate BPD per the definition, outlined in the American Journal of Respiratory and Critical Care Medicine.
|
|
Attending A |
Attending B |
|
FiO2 (% O2) |
40 |
28 |
|
Nasal cannula flow |
1 LPM |
4 LPM |
|
EFiO2 (% O2) |
28.6 |
28 |
|
Target saturations |
91-95% |
91-95% |
|
Diagnosis |
Moderate BPD |
Moderate BPD |
|
Billing code |
99480, Subsequent intensive care infant 2501-5000 grams |
99472, Subsequent inpatient hospital critical care of infant or young child, 29 days through 24 months of age, per day |
|
Working relative value unit (wRVU) |
2.4 |
7.99 |
The interesting observation was the application of different billing codes without changing the diagnostic code (moderate BPD). On the same infant, with the same diagnosis, same effective FiO2, and same oxygen saturation target, different billing codes were applied (See listings on BioPortal here and here). It was interesting to note that the wRVU for Attending A was tripled for Attending B.
In the era of managed care, coding and billing has become an integral part of physician performance and salary. The case presented here highlights the need for careful billing to maximize reimbursement without compromising the medical care of the preterm infant.
In conclusion, the management of BPD may vary among attendings, but a proper billing may generate more wRVU and result in better reimbursement.
Editor’s note: Manzar is an associate professor, department of pediatrics, at the School of Medicine, Louisiana State University Health Sciences Center in Shreveport, Louisiana. Contact him at smanza@lsuhsc.edu. Opinions expressed are those of the author and do not necessarily reflect those of ACDIS, HCPro, or its subsidiaries.