CMS reverses course, allows modifier for newborn care


Physicians can continue to bill for two separate birth-related services on the same day using the "modifier 25," thanks to a recent reversal by officials at the Centers for Medicare and Medicaid Services.

The CMS had changed the coding rules, effective July 1, and barred physicians from using the modifier 25 to bill for both initial inpatient neonatal critical care for evaluation and management (CPT code 99468) and initial hospital or birthing center care for evaluation and management of a normal newborn (CPT code 99460). The agency had said it would not pay physicians for both services when they were performed on the same day.

But after receiving pushback from physicians groups, including the American Academy of Family Physicians, the CMS reversed the decision. In a letter to the medical director of the National Correct Coding Initiative, the AAFP argued that it is not uncommon for family physicians and pediatricians to provide both initial care and ongoing management for a newborn who is initially healthy but deteriorates within hours and needs neonatal intensive care services.

The agency plans to pay physicians retroactively to July 1 for any claims that may be denied. This latest change will be published Oct. 1 in the National Correct Coding Initiative.

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