This document provides an overview of the different levels of neonatal care, from Level I to Level IV. Level I care is for stable newborns receiving routine care and observation. Level II care handles moderately ill newborns needing short-term treatment for conditions like apnea or feeding tubes. Level III is for critically ill infants requiring invasive therapies for respiratory, circulatory or metabolic instability. The highest level, Level IV, cares for very critically ill newborns needing advanced technologies and monitoring for issues such as hemodynamic instability or extracorporeal life support.

1. Presented By
Ms K.V.L.D.Bhavani
Lecturer
Rcn

2. INTRODUCTION
• Admission to and continued stay in appropriate
neonatal levels of care are considered medically
necessary for appropriate care of the neonatal
patient (hospital care starting on date of birth or
immediately afterwards, example if transfer of
care required). If the newborn is admitted to the
NICU during an initial transition period, defined
as 4 hours or less, then discharged back to
Newborn Nursery or pediatric level of care, NICU
level of care will not be assigned regardless of
interventions completed during transitional time

3. • Newborn Level l:
This level of care is for neonates who are
physiologically stable and receiving routine
evaluation, care and observation in the immediate
post-partum period. This billing code can be
utilized by Level I, II, III and IV facilities.
Additional types of services neonates receive or
clinical conditions managed at this level are:

4. • 1. Oral (nipple) feedings for asymptomatic
hypoglycemia not requiring subsequent IV
therapy;
• 2. Routine tests, examples include, but are not
limited to, bilirubin, blood glucose, blood type
and Coombs, direct antiglobulin test (DAT),
complete blood count (CBC) or oximetry.
• 3. Diagnostic work-up/surveillance, on an
otherwise stable neonate where no therapy is

5. 4. Hyper bilirubinemia requiring phototherapy
(single bank only) or bili blanket;
5. Infants transferred from a higher level of care
who are physiologically stable, breathing room
air, in an open crib, and taking either no
medications or on a stable or declining dose of
oral medications and requiring observation to
document successful nipple feeding; 6. Initial
sepsis evaluation (CBC, blood culture for an
asymptomatic neonate) until transfer to higher
level of care

6. • Newborn Level II:
This level provides care for Infants born ≥ 32
weeks gestation and weighing ≥ 1500 grams who
have physiologic immaturity and who are
moderately ill with problems that are expected to
resolve rapidly and are not anticipated to need
subspecialty services on an urgent basis. This
billing code can be utilized by Level II, III and IV
facilities. Examples of the care at this level are:

7. • 1. Apnea/Bradycardia
a. Apnea/Bradycardia episode requiring mild
stimulation;
b. b. Oral pharmacologic treatment for apnea
and/or bradycardic episodes
c. c. Evaluation of apnea of prematurity
2. Feeding via an orally or nasally inserted tube, for
example nasogastric, nasojejunal, or gastrostomy
tube;
3. Services rendered for Neonatal Abstinence
Syndrome (withdrawal) scores less than 8;
4. Hyperbilirubinemia requiring phototherapy more
than single bank or bili blanket.

8. • 5. Incubator/Warmer
a. Documented need for environmental control via an
incubator/warmer for thermoregulation in an otherwise
physiologically stable infant; or
b. Physiologically stable infants in the process of being
weaned from an incubator/warmer to an open crib.
6. Initial medical or surgical sub-specialty consultation;
7. IV Therapy; peripheral or PICC
a. IV fluids (inclusive of hyperalimentation) at high
infusion rate (generally greater than or equal to 50
ml/kg/day); or
b. IV heparin lock medications; or
c. IV medications in a physiologically/clinically stable
infant; or
d. IV treatment of hypoglycemia.

9. 1. Respiratory support
a. High-flow nasal cannula (HFNC) with flow less
than or equal to 3 liters per minute or
b. Supplemental oxygen via oxygen hood or low
flow nasal cannula Page 3 of 10
c. Vapotherm up to 8L/min
9. Sepsis
a. Initial sepsis evaluation (CBC, blood culture,
and other blood tests or cultures) for an
asymptomatic neonate and antibiotic treatment
pending laboratory and/or culture results;
b. b. Sepsis suspected or documented with
treatment (IV/IM [intramuscular] therapies)
beyond the initial 48 hours of treatment.

10. • 10. Services rendered for Neonatal Abstinence
Syndrome (NAS) when the score is greater
than or equal to 8.
• 11. Withdrawal of Life support; end of life
care; palliative care
• 12. Evaluation of temperature instability
requiring isolette or warmer to maintain body
temperature
• 13. Providing mechanical ventilation for brief
duration

11. • Newborn Level III Neonatal Intensive Care:
Infants less than 32 weeks gestational age or less
than 1500 grams birth weight. This level of care is
directed at those neonates that require invasive
therapies and/or are critically ill with respiratory,
circulatory, metabolic or hematologic instabilities
and/or require surgical intervention with general
anesthesia. This billing code can be utilized by
Level III and IV facilities and includes:

12. • Apnea/Bradycardia;
a. IV pharmacologic treatment for apnea and/or
bradycardic episodes; or
b. Requiring bagging or vigorous stimulation
2. Blood or blood product transfusion;
3. Services rendered for Neonatal Abstinence
Syndrome (NAS) when the score is greater
than or equal to 8.
4. Chest tube;
5. Exchange transfusion, partial or complete and
up to 48 hours after exchange transfusion;

13. • 6. IV Therapy;
a. Inborn error of metabolism requiring IV therapy
(BG < 30 at least twice within 12 hour period); or
b. IV bolus or continuous (meaning running at all
times, not repeated intervals) drip therapy for
severe physiologic/metabolic instability (including
blood thinners);
c. Metabolic acidosis or alkalosis or electrolyte
imbalance requiring IV therapy;
d. Seizures requiring IV therapy (this criterion
includes IV glucose administration for seizures
caused by hypoglycemia);
e. Short bowel or "dumping" syndrome requiring total
parenteral nutrition (TPN) at 50 or greater
ml/kg/day.

14. • 7. Respiratory Services
a. High-flow nasal cannula (HFNC) with flow
greater than 3 liters per minute
b. CPAP providing regulated and measured pressure
via mask, nasal or bubble devices;
c. Positive pressure ventilator assistance with
intubation and 24 hours post-ventilator care;
(Note: Intubation in the delivery room [DR]
when the endotracheal tube is removed prior to
leaving the DR or brief intubation for
administration of surfactant or deep tracheal
suctioning does not meet level III criteria for
intubation) o
d. Conditions requiring invasive intervention for
airway protection (i.e. repogle)

15. • 1.Surgical conditions requiring general
anesthesia up to two days post-op if indicated
9. Surgical/Therapies for retinopathy of
prematurity (ROP). Umbilical Artery Catheters
(UACs), Peripheral Artery Catheters (PACs),
Umbilical Vein Catheters (UVCs) and/or
Central Vein Catheters (CVCs) when used for
active monitoring or arterial or venous
pressures or infusion of therapeutic drugs
Peritoneal Dialysis
11. Withdrawal of Life support; end of life care;
palliative care

16. • Newborn Level IV Neonatal Intensive Care:
This level of care covers critically ill neonates
with respiratory, circulatory, metabolic or
hemolytic instabilities as well as conditions
that require surgical intervention. This billing
code can be utilized by Level IV facilities only.
Examples of services provided at this level are:

17. 1. Hemodynamic instability (including
hypertension);
a. Invasive hemodynamic monitoring and CNS
pressure monitoring;
b. Requiring IV volume bolus therapy and/or
inotropic or chronotropic drugs, Ca++ channel
blockers, and IV prostaglandin therapy.
2. High Frequency Ventilation: oscillator or jet
3. Extracorporeal Membrane Oxygenation
(ECMO) / Nitric Oxide (NO);
4. Hypothermia therapy for anoxic damage/HIE,
including selective head cooling

18. 5. Dialysis required
6. Encephalopathy, coma, or other acute
neurologic abnormality
7. Pre and post-surgical care for severe
congenital malformations or acquired
conditions (e.g. gastroschisis, ventricular
septal defect (VSD) or bowel perforation, that
require the use of advanced technology and
support (e.g. IV drips to control blood
pressure, blood product administration,
frequent lab draws, intraspinal medications);
May move to lower level post-op day 1-2

19. 8. Continuous intravenous infusion or intravenous
medication requiring close monitoring or dose
adjustment including 1 or more of the following:
a. Antiarrhythmic agents
b. Neuromuscular blocking agents (e.g.,
pancuronium, vecuronium)
c. Beta-blockers
d. Calcium channel blocking agents
e. Other continuous IV infusion or IV treatment
requiring close monitoring or dose adjustment 9.
CPR in the last 24 hours