CurrentHumanaPolicy CP2022002

Neonatal Intensive Care Unit (NICU) Guidelines

Humana's billing requirements and reimbursement guidelines for NICU stays for specified state Medicaid products; governs claims documentation, DRG assignment and NICU level/ revenue code criteria for providers submitting claims.

Policy Summary

PayerHumana

PolicyNeonatal Intensive Care Unit (NICU) Guidelines

Policy CodePolicy CP2022002

Change TypeNo material change

Effective Date04/2022

Next Review Date04/2026

Key ActionProvide all relevant medical records and documentation during the NICU stay for utilization management and DRG leveling.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

Level 0-4NICU levels described

0174Level 4 revenue code

789-795MS-DRG neonatal range

FL, KY, OK, SC, VA, NCStates listed

NICU Coverage and DRG Minimum Criteria

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DRG 580: A neonate transferred from any hospital who is less than 5 days old and not born at the current hospital.

DRG 588: A neonate who has a birth weight less than 1500 grams with a major procedure.

DRG 589: A neonate who has a birth weight less than 500 grams; or a birth weight of 500 to 999 grams and gestational age less than 24 weeks; or a birth weight of 500 to 749 grams with a major anomaly or without life-sustaining intervention.

Kentucky DRG minimum criteria (partial)

Kentucky Medicaid DRG minimum criteria examples (partial):

DRG 790: A neonate with birth weight <= 999 grams, completed gestational age 23–26 weeks, or diagnosed neonatal RDS (ICD-10-CM P22.0); intended for critically ill neonates requiring the most complex care.

DRG 795: A normal neonate not requiring care outside of the newborn nursery.

Oklahoma DRG minimum criteria (partial)

Oklahoma Medicaid DRG (Nxx) minimum criteria examples (partial):

N01: Applicable MS-DRG 789–795 criteria were satisfied; length of stay < 2 days; neonate died before discharge; neonate was not transferred from another acute care facility.

N14: Applicable MS-DRG 789–795 criteria were satisfied; neonate had birth weight < 750 grams; neonate did not die before discharge.

N49: Applicable MS-DRG 789–795 criteria were satisfied; neonate had birth weight 1500–1999 grams; no OR procedure or only minor surgery (e.g., circumcision).

Coverage criteria for NICU reimbursement — DRG assignment and minimum criteria

DRG assignment and minimum criteria

Assign MS-DRG based on birth weight, gestational age, listed diagnoses and procedures; DRG 790 applies for birth weight <= 999 g, gestational age 23–26 weeks, or neonatal RDS (P22.0).

See state-specific tables for full mappings.

Assign NICU level (0–4) based on reported revenue code and minimum clinical criteria; if documentation for a reported NICU revenue code does not support the criteria, reimbursement will be calculated using the highest NICU revenue code supported by documentation.

Humana reviews reported ICD-10-CM diagnosis codes against peer-reviewed literature definitions and treatment requirements; codes that do not satisfy requirements are excluded from DRG calculation.

Providers must submit all relevant documentation (medical records) during the NICU stay for utilization management and leveling; when multiple DRGs qualify, Humana assigns the DRG associated with the most complex services.

Level 4 coverage criteria examples

Examples of clinical conditions/interventions that meet minimum criteria for Level 4 NICU payment:

Ventilatory support using high frequency oscillating ventilator (HFOV).

Use of IV bolus therapy, inotropic or chronotropic drugs, calcium channel blockers, or IV prostaglandin therapy.

Active seizures requiring anticonvulsants.

Surgical repair of severe congenital defect (examples: omphalocele repair, bowel resection for necrotizing enterocolitis, tracheoesophageal fistula repair).

Inhaled nitric oxide (iNO).

Extracorporeal membrane oxygenation (ECMO).

Therapeutic cooling.

Hyperbilirubinemia requiring exchange transfusion or IVIG administration.

Emergent event (for example, pulmonary arrest or cardiac arrest).

Other listed Level 3 requirements and conditions such as hypoglycemia requiring D-10 bolus, NPO with NG feedings or TPN, services for NAS with specified Finnegan score thresholds.

Revenue, DRG and Diagnosis Codes

NICU revenue codes by levelRevenue

0170	Level 0 revenue code (newborn nursery)
0171	Level 1 NICU revenue code
0172	Level 2 NICU revenue code
0173	Level 3 NICU revenue code
0174	Level 4 NICU revenue code

ICD-10-CM examples discussedICD-10

P22.0	Neonatal respiratory distress syndrome (RDS)
P22.1	Transient tachypnea of the newborn
P22.8	Other respiratory distress of newborn
P22.9	Respiratory distress of newborn, unspecified

MS-DRG neonatal groupmixed

789-795

MS-DRG neonatal categories referenced for assignment

NICU revenue codesRevenue

0170-0174

NICU revenue codes corresponding to Levels 0-4

NICU revenue codingRevenue

0174	Revenue code associated with Level 4 NICU

inv-11: Oxygen support threshold for Level 3

Oxygen threshold> 2 liters per minute of oxygen via nasal cannula (also meets Level 3 if delivered by high flow nasal cannula, CPAP, stable chronic mechanical ventilation, or conventional ventilator)

Alternative ventilatory supportHigh flow nasal cannula or continuous positive airway pressure (CPAP)

Mechanical ventilation optionsStable chronic mechanical ventilation (on home ventilator settings) or conventional ventilator meets Level 3 ventilatory criterion

inv-12: Birth weight and gestational age thresholds referenced in DRG criteria

DRG 790 thresholdsBirth weight <= 999 g; gestational age 23–26 weeks; or diagnosis of neonatal RDS (P22.0)

DRG 791–792 thresholdsBirth weight 1,000–2,499 g or gestational age 27–36 weeks (791 requires one or more CMS Major Problems diagnoses)

DRG 793–794 thresholdsFull-term neonate (>=37 weeks) with diagnoses on CMS Major Problems (793) or Significant Problems (794) lists

DRG 795 thresholdNormal neonate not requiring care outside the newborn nursery

Documentation, DRG Assignment, and Billing Actions

Documentation Required

Medical necessity and plan requirements

In addition to this policy, claims payments are subject to other plan requirements for the processing and payment of claims, including, but not limited to, requirements of medical necessity and reasonableness and applicable referral or authorization requirements. To be reimbursed for a medically necessary NICU stay subject to DRG-based pricing, the provider must satisfy the requirements in this policy and any applicable state or plan-specific guidance. Payments are subject to verification of medical necessity and reasonableness; missing or insufficient documentation, lack of required referrals/authorizations, or failure to meet plan-specific criteria may result in denial or re-pricing of the claim.

Providers must supply all relevant medical records and documentation for utilization management and DRG leveling.
Humana uses submitted documentation to assign the DRG; when multiple DRGs could apply, Humana assigns the DRG corresponding to the most complex services.
Providers should follow any state-specific billing or reporting guidance (for example, OHCA requirements for Oklahoma).

Documentation Required

Level 4 NICU admission criteria and example services

Level 4 NICU care (Revenue code 0174) requires that Level 3 criteria are met and that the neonate has an additional condition requiring ongoing evaluation, active management, or therapy adjustment with near-continuous nursing and medical support. Examples of services/conditions that support Level 4 admission include: ventilatory support using high frequency oscillating ventilator (HFOV); extracorporeal membrane oxygenation (ECMO); inhaled nitric oxide (iNO); therapeutic cooling; surgical repair of severe congenital defects (for example, omphalocele repair, bowel resection for necrotizing enterocolitis, tracheoesophageal fistula repair); use of IV bolus therapy or inotropic/chronotropic drugs; active seizures requiring anticonvulsants; hyperbilirubinemia requiring exchange transfusion or IVIG; emergent events (eg, pulmonary or cardiac arrest).

Revenue code = 0174
Level 4 admission requires that Level 3 requirements are already met plus one or more Level 4 indicators listed above
Document the specific service, monitoring, medication, or procedure that justifies Level 4 care in the medical record and on the claim.

Key Terms and NICU Level Definitions

inv-17: Definition — Neonate

DefinitionNeonate: An infant who is less than four weeks old.

ContextUsed throughout policy to determine eligibility for neonatal DRG assignment and level-of-care definitions.

Related termsPrematurity and extreme prematurity are defined separately by gestational age in this policy.

inv-18: Definition — Prematurity / Extreme prematurity

PrematurityBirth before 37 weeks and zero days gestational age.

Extreme prematurityBirth before 28 weeks and zero days gestational age.

RelevanceGestational age categories are used in DRG minimum criteria (e.g., 23–26 wks, 27–36 wks, >=37 wks).

inv-19: Definition — Neonatal respiratory distress syndrome (RDS)

DefinitionNeonatal respiratory distress syndrome (RDS): Occurs when there is a deficiency of surfactant (ICD-10-CM P22.0), primarily due to prematurity.

Clinical featuresClassic chest X-ray: diffuse atelectasis, ground-glass appearance, air bronchograms, low lung volumes.

TreatmentSurfactant therapy and assisted ventilation (ventilator, CPAP, high flow oxygen) with monitoring and supportive care.

inv-20: Level 0 definition (Revenue code 0170)

Revenue code0170

Level nameLevel 0 (Newborn nursery observation)

ExamplesObservation care such as sepsis observation

inv-21: Level 1 definition (Revenue code 0171)

Revenue code0171

Level nameLevel 1 (Newborn nursery with instability)

Criteria examplesTemperature instability, feeding irregularities, jaundice

inv-22: Level 2 definition (Revenue code 0172)

Revenue code0172

Level nameLevel 2 (Requires more nursing/medical care)

Criteria examplesHood oxygen or <= 2 L/min via nasal cannula; IV heplock medicines; phototherapy; documented apnea/bradycardia/desaturation; NAS services with Finnegan <=8

inv-23: Level 3 definition (Revenue code 0173)

Revenue code0173

Level nameLevel 3 (Meets Level 2 plus temperature control and requires 6–12 hours of active nursing/medical support)

Clinical evidence/examplesIsolette or radiant warmer in use plus one or more: >2 L/min via nasal cannula, high flow nasal cannula, CPAP, conventional ventilator, UVC or invasive cardiopulmonary monitoring, hypoglycemia needing D-10 bolus, NPO with NG feeds or TPN, NAS meeting specified Finnegan thresholds

inv-24: Level 4 definition (Revenue code 0174) — clinical examples

Revenue code0174

Level nameLevel 4 (Near-continuous nursing/medical support for ongoing evaluation/therapy adjustment)

Clinical examplesHFOV, IV bolus/inotropes/chronotropes/IV prostaglandin, active seizures requiring anticonvulsants, surgical repair of severe congenital defects (omphalocele, NEC bowel resection, tracheoesophageal fistula), inhaled nitric oxide, ECMO, therapeutic cooling, exchange transfusion or IVIG for hyperbilirubinemia, emergent events (pulmonary or cardiac arrest)

inv-25: Level 4 NICU — summary definition

Summary definitionLevel 4 NICU: Care that meets Level 3 requirements plus a condition requiring ongoing evaluation, active management, or therapy adjustment with near-continuous nursing and medical support.

Triggers/examplesIncludes one or more critical interventions or conditions such as HFOV, ECMO, inhaled nitric oxide, therapeutic cooling, exchange transfusion/IVIG, IV inotropes/bolus therapy, active seizures, or surgical repair of severe congenital defects.

Documentation noteProviders must document the specified interventions/conditions to support Level 4 revenue code 0174 and DRG-based reimbursement.