93 - Reimbursement Modeling for Infants with Neonatal Opioid Withdrawal Syndrome Following Implementation of the Eating, Sleeping, Consoling Care Approach

Publication Number: 3089.93

Leslie Young, The University of Vermont Children's Hospital, Burlington, VT, United States; Arnie P. Aldridge, RTI International, Chapel Hill, NC, NC, United States; Stephanie L. Merhar, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Kate Stanley, University of Michigan Medical School, Ann Arbor, MI, United States; Lillian Trochinski, RTI International, Brookfield, WI, United States; Abhik Das, RTI, Gaithersburg, MD, United States; Scott Duncan, University of Louisville School of Medicine, Louisville, KY, United States; Lori A. Devlin, University of Louisville School of Medicine, Louisville, KY, United States; for the Eunice Kennedy Shriver NICHD Neonatal Research Network and the, RTI International, Durham, NC, United States

Background: Infants exposed to opioids in utero need close monitoring and supportive care following delivery. With the advent of the Eating, Sleeping, Consoling care approach, much of the care for infants with neonatal opioid withdrawal syndrome (NOWS), including those with moderate-to-severe withdrawal, has moved from the NICU to non-ICU settings. This shift has stressed systems that have historically not provided this level of care. In response, some institutions have adjusted staffing ratios and reallocated resources to facilitate use of this evidence-based approach. However, others have raised concerns about the potential loss of revenue for hospitals using the ESC care approach, due to decreased NICU admissions. The potential impact of varied institutional billing practices on reimbursement for infants with NOWS has not been described.

Objective: To illustrate the potential variation in and impact of varied billing practices and opportunities for institutional practices to more accurately reflect the clinical care being provided with the ESC care approach.

Design/Methods: To characterize institutional practice variation, we created and applied three reimbursement scenarios based on the ESC-NOW study using CMS standards. Infants in the ESC group who did not receive pharmacologic treatment were included and assumed to have received care in a non-ICU setting. Scenarios were constructed using internally consistent combinations of ICD-10, facility DRG, and physician fee CPT codes to reflect the potential range of reimbursement. The spectrum of scenarios included an erroneous scenario, likely used mistakenly by some, and two scenarios based on clinical complexity. The erroneous scenario did not account for opioid exposure and assigned healthy newborn reimbursement codes. The additional scenarios accounted for exposure with/without signs of withdrawal and management in non-ICU settings.

Results: The study included 458 infants, with a mean length of stay of 5.8 days. Per infant reimbursement was $1,911 (95%CI:1,881-1,941) with the erroneous scenario applied, $10,120 (95%CI:10,100-10,141) with the low complexity scenario, and $27,627 (95%CI:27,607-27,648) with the typical complexity scenario (table1). The estimated opportunity cost between the erroneous and typical complexity scenarios was $25,716 per infant.

Conclusion(s): Use of the ESC care approach does not need to result in a consequential loss of revenue. Intentional documentation and billing practices that are commensurate with the clinical care being provided in non-ICU settings could help support allocation of essential resources to facilitate use of this approach.

Reimbursement Scenarios Modeling Potential Variation in Billing Practice and Reimbursement for Infants Cared for Using the ESC Care Approach who received Non-pharmacologic Care in Non-ICU Settings


Primary ICD-10 Code Assignment and Mapping for Infants with Prenatal Opioid Exposure
*Note: Although not included in this study, an infant with typical complexity (i.e. ICD-10 P96.1, DRG 793) but cared for in the NICU (e.g. receiving pharmacologic treatment) would have different physician CPT codes applied for NICU care (99477, 99480, 99239), this would result in a slightly higher reimbursement than the typical complexity scenario presented ($27,955 vs. $27,627, respectively).

Coding Best Practices and Supportive Documentation for Infants with Prenatal Opioid Exposure