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DRG Newborn Inpatient Stays - Facility
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Reimbursement rules for newborn inpatient stays including DRG-to-revenue-code matching and neonatal levels of care that affect facility billing and authorization requirements for Blue Cross Blue Shield - Maine members.
No material clinical or coverage changes in this revision.
Newborn Inpatient Reimbursement Criteria
Newborn inpatient reimbursement criteria
Reimbursement and grouping rules for newborn inpatient stays.
DRG-based reimbursement
- When reimbursement is based on a Diagnosis Related Group (DRG), the claim must include the appropriate revenue code that matches the corresponding DRG.
- If there is no Neonatal Intensive Care Unit (NICU) revenue code listed on the claim, the claim will not group to a sick newborn DRG.
DRG assignments
- Normal newborn DRG codes must be billed with the appropriate well-newborn revenue codes (e.g., 0170).
- Sick newborn DRG codes must be billed with the appropriate sick-newborn/NICU revenue codes (e.g., 0172-0174).
Revenue-code-based reimbursement
- When reimbursement is based on the revenue code, neonatal level of care is determined by the revenue code submitted on the claim and must align with the definitions for revenue codes 0170–0174.
Well-baby (Revenue code 0170) criteria
- Revenue code 0170 (General Nursery or Well-Baby) is for healthy neonates who are physiologically stable and receiving evaluation and observation in the immediate post-partum period; care may occur in a nursery or maternal rooming-in.
- Infants weighing >= 2000 grams at birth and clinically stable infants >= 35 weeks gestational age may be cared for in a well-baby nursery (0170).
Higher-level neonatal care (Revenue codes 0171–0174)
- 0171 (Level I Surveillance 'Special Care Nursery') — medically stable neonates who require surveillance/care at a higher level than the general nursery.
- 0172 (Level II Neonatal Intensive Care) — newborns with physiologic immaturity combined with medical instabilities.
- 0173 (Level III Neonatal Intensive Care) — neonates who require invasive therapies and/or are critically ill (respiratory, circulatory, metabolic, or hematologic instabilities) and/or require surgical intervention with general anesthesia.
- 0174 (Level IV Neonatal Intensive Care) — hemodynamically unstable or critically ill neonates, including those requiring surgical intervention and the first 24 hours of monitoring of infants with major congenital anomalies or extreme prematurity.
Revenue Codes and Weight/Gestational Criteria
| 0170 | General Nursery or Well-Baby |
| 0171 | Level I Surveillance 'Special Care Nursery' |
| 0172 | Level II Neonatal Intensive Care |
| 0173 | Level III Neonatal Intensive Care |
| 0174 | Level IV Neonatal Intensive Care |
Authorization and Provider Responsibilities
Authorization requirement for newborn inpatient stays
Current authorization guidelines for newborn inpatient stays must be followed in addition to the coding and billing requirements described in this policy.
Neonatal Level Definitions (Revenue Codes)
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