CurrenthealthnetnationalPolicy N/A

Alere neonatal level of care criteria

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Defines clinical criteria for assigning neonatal inpatient level of care (NICU, Transitional, Convalescent, Detained/Normal) and associates each with a revenue code; affects hospitals, clinicians, and utilization reviewers determining appropriate level of care.

Policy Summary

Payerhealthnetnational

PolicyAlere neonatal level of care criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSupport level assignment with clinical documentation and note any consultations with the Alere Care Manager or Medical Director when performed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4distinct level-of-care categories defined

11NICU criteria listed

7Transitional criteria listed

12Convalescent criteria listed

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CurrenthealthnetnationalPolicy N/A

Alere neonatal level of care criteria

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Sign up for all healthnetnational policy alerts

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Policy Summary

Payerhealthnetnational

PolicyAlere neonatal level of care criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSupport level assignment with clinical documentation and note any consultations with the Alere Care Manager or Medical Director when performed.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

4distinct level-of-care categories defined

11NICU criteria listed

7Transitional criteria listed

12Convalescent criteria listed

Neonatal Level-of-Care Assignment Criteria

NICU (174)

NICU - Revenue Code 174: Assign when ANY of the following are present

NICU criteria: 1. Ventilator/Intubated; 2. Extracorporeal Membrane Oxygenation (ECMO) / Nitric Oxide (NO); 3. Any nasal flow delivered at > 2 lpm. For infants < 1 kg, any nasal flow delivered at > 1 lpm; 4. Chest Tube; 5. Exchange transfusion, dialysis; 6. IV bolus or continuous drip therapy for severe physiologic/metabolic instability; 7. Apnea/bradycardia > 10 day all requiring tactile stimulation or any episodes requiring Positive Pressure Ventilation (PPV); 8. Unstable vital signs requiring therapy or conditions requiring frequent Vital Signs (Medical Director consultation required prior to assignment).

Transitional (173)

Transitional - Revenue Code 173: Assign when ANY of the following are present

Transitional criteria: 1. Isolette/Warmer for thermoregulation; 2. Static decreased oxygen requirement via nasal cannula (≤ 2 lpm) or hood; 3. Enteral nutrition delivered by methods other than p.o.; 4. Intravenous fluids/blood transfusion; 5. Initial sepsis evaluation (CBC, blood culture and treatment in an asymptomatic patient on the first day of evaluation); 6. Apnea/bradycardia not meeting criteria in NICU level of care; 7. Neonatal abstinence syndrome when NAS scores are ≥ 8 on three consecutive scores or ≥ 12 on two consecutive scores (Medical Director consult required prior to assignment).

Convalescent (172)

Convalescent - Revenue Code 172: Assign when ANY of the following are present

Convalescent criteria: 1. Phototherapy - intensive (double phototherapy or greater); 2. IV heplock meds; 3. Neonatal abstinence syndrome when NAS scores are < 8; 4. No Apnea/Bradycardia (greater than 48 hours since last episode, and otherwise meeting detained Level of Care I criteria); 5. Diagnostic work-up/surveillance, otherwise stable using >1 consultant and/or diagnostic test; 6. Temperature instability; 7. Advancing to full volume feeds; 8. Stable with sub-optimal PO; 9. Apnea countdown; 10. Post hemorrhagic hydrocephalus; 11. Growing preemie; 12. Growing preemie who is stable except O2 with feeds.

Detained/Normal (171)

Detained/Normal - Revenue Code 171: Assign when ANY of the following are present

Detained/Normal criteria: 1. Diagnostic work-up/surveillance otherwise stable using 1 consultant or diagnostic test; 2. Routine well baby care; 3. Phototherapy (single source phototherapy).

There are no explicit exclusions listed in this policy beyond the clinical criteria that define each level of neonatal inpatient care. Final determinations about level assignment are explicitly subject to interpretation by the Alere Care Manager and Medical Director. The hospital representative may discuss or appeal a determination with the Alere Care Manager and/or Medical Director, and any such discussions or appeals should be documented in the medical record.

If a patient does not meet the clinical criteria listed for a higher-level revenue code, the policy indicates that provision of that higher-level care would not be supported. In practice this means the level of care should be assigned based on the objective items enumerated for each revenue code (for example, respiratory support thresholds, invasive therapies, monitoring needs). Documentation must demonstrate that the patient meets at least one listed criterion for the assigned level; failure to do so may lead to review or challenge by the Alere Care Manager or Medical Director.

Revenue Codes and Numeric Thresholds

NICU Revenue CodeRevenue

174	Revenue Code 174 (NICU criteria)

Transitional Revenue CodeRevenue

173	Revenue Code 173 (Transitional criteria)

Convalescent Revenue CodeRevenue

172	Revenue Code 172 (Convalescent criteria)

Detained/Normal Revenue CodeRevenue

171	Revenue Code 171 (Detained/Normal criteria)

Nasal flow thresholds

General nasal flow threshold> 2 LPM

Infants < 1 kg nasal flow threshold> 1 LPM

ContextAny nasal flow delivered above these thresholds meets NICU criteria as specified in Revenue Code 174

NAS scoring thresholds

Transitional NAS thresholdNAS ≥ 8 on three consecutive scores OR NAS ≥ 12 on two consecutive scores (Medical Director consult required prior to assignment)

Convalescent NAS thresholdNAS scores < 8

Clinician & Reviewer Actions, Consults, and Documentation

Prior Authorization

Obtain Medical Director consult before certain NICU/Transitional assignments

Medical Director consultation is required before assigning certain higher-level care: specifically, NICU assignments for 'Unstable vital signs requiring therapy or conditions requiring frequent Vital Signs' and Transitional assignments for NAS meeting the listed thresholds. Obtain and document the Medical Director consult prior to assigning these levels.

NICU: "Unstable vital signs requiring therapy or conditions requiring frequent Vital Signs. (Medical Director consultation required prior to assignment)."
Transitional: "Neonatal abstinence syndrome ... greater than or equal to 8 on three consecutive scores or greater than or equal to 12 on two consecutive scores. (Medical Director consult required prior to assignment)"

Step Therapy

Step therapy: none specified in policy

No step therapy instructions are provided in this policy. If a step requirement becomes relevant, follow the Medical Director/Alere Care Manager process in this document.

Policy Background

This document defines four neonatal inpatient levels of care tied to revenue codes: NICU (174), Transitional (173), Convalescent (172), and Detained/Normal (171). Each level is justified when a patient meets any of the specific clinical criteria listed under that revenue code (for example, ventilator or ECMO support and nasal flow thresholds in NICU; isolette, enteral feeding methods, or NAS scoring in Transitional; phototherapy intensity and stability metrics in Convalescent; routine well-baby care or single-source phototherapy in Detained/Normal). Level-of-care determinations are intended to be applied using these objective criteria and may be reviewed by the Alere Care Manager or Medical Director when interpretation is needed.

Levels of Care Definitions

Levels of Care (revenue codes and descriptors)

NICURevenue Code 174 — highest acuity (e.g., ventilator, ECMO, any nasal flow >2 LPM [>1 LPM if <1 kg], chest tube)

TransitionalRevenue Code 173 — intermediate care (e.g., isolette/warmer, oxygen ≤2 LPM or hood, enteral feeds not PO, IV fluids)

ConvalescentRevenue Code 172 — lower acuity recovery (e.g., intensive phototherapy, IV heplock meds, NAS scores <8)

Detained/NormalRevenue Code 171 — routine/well-baby or diagnostic surveillance with single consultant/test (single-source phototherapy)