Is neonatal really neonatal? How statistics can be warped through misunderstanding

 

Whether you work in a dedicated children’s hospital or a general hospital with a pediatric service line, you will likely come into contact with coding charts of kids. Sometimes they are easy (e.g., an inguinal hernia repair without obstruction or gangrene is an inguinal hernia repair without obstruction or gangrene—except it has to be identified as right or left in ICD-10). Sometimes they are not so easy (e.g., complex congenital diseases and their manifestations and complications).

 

Stuff happens to children at all times of their short lives. Sometimes it’s related to prematurity, sometimes to congenital or genetic defects or abnormalities. Some things are related to the birth process, some things happen regardless of relationship to the birth process. It is this last piece that I want to discuss this month.

 

When is “neonatal” neonatal? And specifically, when isn’t it?

 

First of all, we have to know a couple of things as background.

 

The Official ICD-9-CM Guidelines for Coding and Reporting talk about the perinatal and newborn period as being the first 28 days of life. This was designed specifically to aid in defining how many deaths occurred in the first 28 days of life. Using additional indicators—such as length of pregnancy to identify prematurity, relationship to congenital or genetic deficiencies or abnormalities, capturing the diseases that supervened related to full-term babies vs. babies of varying levels of prematurity—was a good system. At least the intent was good.

 

But what people don’t turn their attention to as much as they should is the subsequent Official Guideline that states:

If a newborn has a condition that may be either due to the birth process or community acquired and the documentation does not indicate which it is, the default is due to the birth process and the code from Chapter 15 should be used. If the condition is community acquired, a code from Chapter 15 should not be assigned.

And why don’t they? Because the DRG assignment for many of these cases being identified as a neonatal event has two to five times the relative weight of the corresponding non-neonatal version. After all, why not shoot for DRG 793 when a 27-day, 23-hour, and 59-minute-old patient comes in with hypoxia from pneumonia by sequencing 770.88 (hypoxia of newborn) as a principal diagnosis and 486 (pneumonia, organism unspecified) as a secondary diagnosis? You get a relative weight of almost 3.5.

If the patient were admitted two minutes later, you’d lose the neonatal code and get DRG 195 with a mere 0.70 relative weight. Who cares that the patient was given one dose of IV antibiotics and discharged the next morning? We get lots of dollars. Who cares that we were reported as having a full-term neonate suffering a major complication of birth?

 

Well, who’s going to take the trouble to ask the physician whether the pneumonia was related to the process of being born or was a congenital issue when we can get five times the number of dollars? Not me.

 

Okay, here’s the next issue: definitions and semantics. A newborn is a child who was just born. The neonatal period is the first 28 days of life for the purposes of mortality statistics. These are not the same thing. They were not intended to be the same thing. They have been misinterpreted as being the same thing. Why? For dollars.

 

 Coders report congenital abnormalities with codes in the 740–759 series. Diseases in the 760–779 series are supposed to represent conditions related to the process of being born, from the world of the mother’s womb to the “stuff” that can happen to the child in the process of being born, even if the condition is not identified until later in life. All of these conditions are related to the process of being born.

They are all intended to be related to things that can happen to the newly born human being—the newborn. Whether the condition in the newborn is related to:

All of these codes are intended to relate to the process of being a newly born human being and were not intended to measure things that happened to the person in the first 28 days of life that are totally unrelated to the process of being born.

 

We don’t get a lot of help from other authorities that give us advice for coding; they make the same mistakes. They confuse a newly born human being who got hurt between the sperm and egg to the drive down the birth canal with existence during the first 28 days of life after a totally normal pregnancy and delivery. What we have to do is fix it.

 

Statistically, we have very complicated newborn existences in this country rivalling some countries with considerable deficiencies in medical care because nobody asked the right questions.

 

 There is a thing called “intent of the codes” and there is “use of the codes.” When these two concepts don’t jibe, statistics get warped and reimbursement gets warped.

 

Let’s look at what’s going to happen with ICD-10. The ICD-10-CM Official Guidelines for Coding and Reporting is already out. Has it gotten better? Well, turns out that other than changing the title of the chapter from Chapter 15 to Chapter 16 and the look of the code sets, the advice is exactly the same.

We need to be smarter than the advice. Here’s the deal: If the child had an uneventful full-term gestation and delivery, history shows that other kids in the house had bronchiolitis with respiratory syncytial virus (RSV), and this 26-day-old got bronchiolitis with RSV, doesn’t it look like it was not due to the process of being born?

 

A 3-week-old child who has been developing normally, gaining weight, and eating well comes in after being scared by an older brother and aspirating a glob of thickened formula. The 3-week-old develops some wheezing. Is that 770.18 (newborn aspiration of something other than blood, gastric juice, amniotic fluid with respiratory symptoms), or is that totally unrelated to the process of being born?

 

If that same child was in an automobile accident and experienced a pulmonary contusion from a front-end collision and developed respiratory failure, was that caused by the birth process and should it be coded to 770.84 (respiratory failure in a newly born human being), or was this obviously unrelated to the birth process?

 

We have to be smarter than the advice. We have to do what’s right regardless of the financial impact. 

 

Editor’s note: Dr. Gold is CEO of DCBA, Inc., a consulting firm in Atlanta that provides physician-to-physician CDI programs. Contact him at 770-216-9691 orrgold@DCBAInc.com.