LEVELS OF NEONATAL CARE.pptx

GIVES KNOWLEDGE

1. Presented By Ms K.V.L.D.Bhavani Lecturer Rcn Levels Of Neonatal Care

2. INTRODUCTION Admission to and continued stay in appropriate neonatal levels of care are considered medically necessary for appropriate care of the neonatal patient (hospital care starting on date of birth or immediately afterwards, example if transfer of care required). If the newborn is admitted to the NICU during an initial transition period, defined as 4 hours or less, then discharged back to Newborn Nursery or pediatric level of care, NICU level of care will not be assigned regardless of interventions completed during transitional time

3. Newborn Level l: This level of care is for neonates who are physiologically stable and receiving routine evaluation, care and observation in the immediate post-partum period. This billing code can be utilized by Level I, II, III and IV facilities. Additional types of services neonates receive or clinical conditions managed at this level are:

4. 1. Oral (nipple) feedings for asymptomatic hypoglycemia not requiring subsequent IV therapy; 2. Routine tests, examples include, but are not limited to, bilirubin , blood glucose, blood type and Coombs, direct antiglobulin test (DAT), complete blood count (CBC) or oximetry . 3. Diagnostic work-up/surveillance, on an otherwise stable neonate where no therapy is

5. 4. Hyper bilirubinemia requiring phototherapy (single bank only) or bili blanket; 5. Infants transferred from a higher level of care who are physiologically stable, breathing room air, in an open crib, and taking either no medications or on a stable or declining dose of oral medications and requiring observation to document successful nipple feeding; 6. Initial sepsis evaluation (CBC, blood culture for an asymptomatic neonate) until transfer to higher level of care

6. Newborn Level II: This level provides care for Infants born ≥ 32 weeks gestation and weighing ≥ 1500 grams who have physiologic immaturity and who are moderately ill with problems that are expected to resolve rapidly and are not anticipated to need subspecialty services on an urgent basis. This billing code can be utilized by Level II, III and IV facilities. Examples of the care at this level are:

7. 1. Apnea/ Bradycardia Apnea/ Bradycardia episode requiring mild stimulation; b. Oral pharmacologic treatment for apnea and/or bradycardic episodes c. Evaluation of apnea of prematurity 2. Feeding via an orally or nasally inserted tube, for example nasogastric , nasojejunal , or gastrostomy tube; 3. Services rendered for Neonatal Abstinence Syndrome (withdrawal) scores less than 8; 4. Hyperbilirubinemia requiring phototherapy more than single bank or bili blanket.

8. 5. Incubator/Warmer Documented need for environmental control via an incubator/warmer for thermoregulation in an otherwise physiologically stable infant; or b. Physiologically stable infants in the process of being weaned from an incubator/warmer to an open crib. 6. Initial medical or surgical sub-specialty consultation; 7. IV Therapy; peripheral or PICC IV fluids (inclusive of hyperalimentation ) at high infusion rate (generally greater than or equal to 50 ml/kg/day); or IV heparin lock medications; or IV medications in a physiologically/clinically stable infant; or IV treatment of hypoglycemia.

9. Respiratory support High-flow nasal cannula (HFNC) with flow less than or equal to 3 liters per minute or b. Supplemental oxygen via oxygen hood or low flow nasal cannula Page 3 of 10 c. Vapotherm up to 8L/min 9. Sepsis Initial sepsis evaluation (CBC, blood culture, and other blood tests or cultures) for an asymptomatic neonate and antibiotic treatment pending laboratory and/or culture results; b. Sepsis suspected or documented with treatment (IV/IM [intramuscular] therapies) beyond the initial 48 hours of treatment.

10. 10. Services rendered for Neonatal Abstinence Syndrome (NAS) when the score is greater than or equal to 8. 11. Withdrawal of Life support; end of life care; palliative care 12. Evaluation of temperature instability requiring isolette or warmer to maintain body temperature 13. Providing mechanical ventilation for brief duration

11. Newborn Level III Neonatal Intensive Care: Infants less than 32 weeks gestational age or less than 1500 grams birth weight. This level of care is directed at those neonates that require invasive therapies and/or are critically ill with respiratory, circulatory, metabolic or hematologic instabilities and/or require surgical intervention with general anesthesia. This billing code can be utilized by Level III and IV facilities and includes:

12. Apnea/ Bradycardia ; IV pharmacologic treatment for apnea and/or bradycardic episodes; or b. Requiring bagging or vigorous stimulation 2. Blood or blood product transfusion; 3. Services rendered for Neonatal Abstinence Syndrome (NAS) when the score is greater than or equal to 8. 4. Chest tube; 5. Exchange transfusion, partial or complete and up to 48 hours after exchange transfusion;

13. 6. IV Therapy; Inborn error of metabolism requiring IV therapy (BG < 30 at least twice within 12 hour period); or b. IV bolus or continuous (meaning running at all times, not repeated intervals) drip therapy for severe physiologic/metabolic instability (including blood thinners); c. Metabolic acidosis or alkalosis or electrolyte imbalance requiring IV therapy; d. Seizures requiring IV therapy (this criterion includes IV glucose administration for seizures caused by hypoglycemia); e. Short bowel or "dumping" syndrome requiring total parenteral nutrition (TPN) at 50 or greater ml/kg/day.

14. 7. Respiratory Services High-flow nasal cannula (HFNC) with flow greater than 3 liters per minute b. CPAP providing regulated and measured pressure via mask, nasal or bubble devices; c. Positive pressure ventilator assistance with intubation and 24 hours post-ventilator care; (Note: Intubation in the delivery room [DR] when the endotracheal tube is removed prior to leaving the DR or brief intubation for administration of surfactant or deep tracheal suctioning does not meet level III criteria for intubation) o d. Conditions requiring invasive intervention for airway protection (i.e. repogle )

15. 1.Surgical conditions requiring general anesthesia up to two days post-op if indicated 9. Surgical/Therapies for retinopathy of prematurity (ROP). Umbilical Artery Catheters (UACs), Peripheral Artery Catheters (PACs), Umbilical Vein Catheters (UVCs) and/or Central Vein Catheters (CVCs) when used for active monitoring or arterial or venous pressures or infusion of therapeutic drugs Peritoneal Dialysis 11. Withdrawal of Life support; end of life care; palliative care

16. Newborn Level IV Neonatal Intensive Care: This level of care covers critically ill neonates with respiratory, circulatory, metabolic or hemolytic instabilities as well as conditions that require surgical intervention. This billing code can be utilized by Level IV facilities only. Examples of services provided at this level are:

17. Hemodynamic instability (including hypertension); a. Invasive hemodynamic monitoring and CNS pressure monitoring; b. Requiring IV volume bolus therapy and/or inotropic or chronotropic drugs, Ca++ channel blockers, and IV prostaglandin therapy. 2. High Frequency Ventilation: oscillator or jet 3. Extracorporeal Membrane Oxygenation (ECMO) / Nitric Oxide (NO); 4. Hypothermia therapy for anoxic damage/HIE, including selective head cooling

18. 5. Dialysis required 6. Encephalopathy, coma, or other acute neurologic abnormality 7. Pre and post-surgical care for severe congenital malformations or acquired conditions (e.g. gastroschisis , ventricular septal defect (VSD) or bowel perforation, that require the use of advanced technology and support (e.g. IV drips to control blood pressure, blood product administration, frequent lab draws, intraspinal medications); May move to lower level post-op day 1-2

19. 8. Continuous intravenous infusion or intravenous medication requiring close monitoring or dose adjustment including 1 or more of the following: Antiarrhythmic agents Neuromuscular blocking agents (e.g., pancuronium , vecuronium ) Beta-blockers d. Calcium channel blocking agents e. Other continuous IV infusion or IV treatment requiring close monitoring or dose adjustment 9. CPR in the last 24 hours