CurrentBlue Cross Blue Shield - New MexicoPolicy CPCPO04

Neonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy

Defines billing, documentation, and reimbursement requirements for NICU inpatient services and revenue code level assignment for Blue Cross and Blue Shield of New Mexico members and providers.

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyNeonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy

Policy CodePolicy CPCPO04

Change TypeAnnual review (no material coverage change)

Effective Date07/29/2024

Next Review Date

Key ActionSubmit documentation that demonstrates alignment with MCG Intensity of Care Guidelines to support NICU level assignment and continued authorization.

SourceLink

POLICY UPDATE CHANGES

Annual review conducted on 07/22/2024.

4NICU levels of care represented

0171-0174Associated inpatient revenue codes by level

LOC-010 to LOC-013Referenced MCG guideline locators

07/29/2024Plan effective date

NICU Coverage & Reimbursement Criteria

NICU coverage and reimbursement criteria

NICU level assignment and reimbursement are contingent on documentation meeting MCG intensity-of-care criteria and correct revenue code billing.

Claims and reimbursement for NICU inpatient services require documentation that substantiates the assigned NICU level of care and the corresponding revenue code.

ALL of the following

Assign revenue code 0171 for Level 1, 0172 for Level 2, 0173 for Level 3, and 0174 for Level 4; any inpatient revenue codes not billed as levels 2-4 will be recognized as Level 1.
Level descriptions and associated MCG Intensity of Care locators: Level 1 — MCG LOC-010; Level 2 — MCG LOC-011; Level 3 — MCG LOC-012; Level 4 — MCG LOC-013.

ALL of the following

Policy Summary

PayerBlue Cross Blue Shield - New Mexico

PolicyNeonatal Intensive Care Unit (NICU) Level of Care Authorization and Reimbursement Policy

Policy CodePolicy CPCPO04

Change TypeAnnual review (no material coverage change)

Effective Date07/29/2024

Next Review Date

Key ActionSubmit documentation that demonstrates alignment with MCG Intensity of Care Guidelines to support NICU level assignment and continued authorization.

SourceLink

On This Page

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Revenue Codes and Documentation Alignment

NICU revenue codes by levelRevenueCovered

0171	Newborn Level - Level 1 NICU revenue code
0172	Newborn - Level 2 NICU revenue code
0173	Newborn Level - Level 3 NICU revenue code
0174	Newborn Level - Level 4 NICU revenue code

Documentation alignment

RequirementLevel of care and corresponding revenue code assignment must align with the MCG Intensity of Care Guidelines (LOC-010 through LOC-013) to support billing and reimbursement.

Supporting documentationClaims must be supported by clinical documentation establishing that the NICU level-of-care/intensity criteria are satisfied; the Plan may request supporting documentation.

Concurrent reviewClinical documentation of ongoing NICU hospitalizations may be reviewed concurrently to substantiate the level of care.

Impact on claimsFailure to adhere to coding and billing policies may impact claims processing and reimbursement.

Authorization, Documentation, and Review Requirements

Documentation Required

Authorization and documentation requirements

Continued authorizations for ongoing NICU hospitalizations will be determined based on the documentation submitted and must align with the MCG Intensity of Care Guidelines (LOC-010 to LOC-013). The Plan reserves the right to request supporting documentation and may deny or adjust claims if documentation does not substantiate the assigned NICU level or revenue code.

Continued authorizations based on submitted documentation must align with MCG Intensity of Care Guidelines (LOC-010 to LOC-013).
The Plan reserves the right to request supporting documentation; failure to adhere to coding and billing policies may impact claims processing and reimbursement.

Prior Authorization

Concurrent review of inpatient admissions

Inpatient NICU admissions and ongoing hospitalizations may be reviewed concurrently to verify appropriate duration and level of care; clinical documentation may be reviewed during the admission to substantiate the assigned NICU level and revenue code.

Inpatient admissions may be reviewed to ensure services are an appropriate duration and level of care.
Clinical documentation of ongoing NICU hospitalizations may be reviewed concurrently to substantiate level of care.

Key Definitions

Neonatal Intensive Care Unit (NICU)

DefinitionA critical care area in a facility for newborn babies who need specialized care.

ScopeIncludes facilities, hospitals, physicians, and other qualified health care professionals providing NICU services.

Purpose of policyProvides billing and reimbursement information for when NICU services are rendered and assigns revenue codes to NICU levels.

External clinical criteria

External criteria referencedMCG Intensity of Care Guidelines (LOC-010 through LOC-013) are used to substantiate NICU level of care and continued authorization.

Access to guidelinesMCG Care Guidelines can be accessed through Availity Essentials as a resource.

Role of MCGMCG Health administers the guidelines as an independent company under contract with BCBSNM; BCBSNM makes no endorsement of third-party vendors.