EM Coding Alert

Use just one diagnosis code with a normal newborn CPT®.

Birth through 28 days is the definition of “newborn” according to CPT® and ICD-9. But that isn’t the only definition you need to learn to select the right E/M code for your physician’s newborn encounters. You’ll also need to differentiate “normal” and “sick” to be able to find the code you need. 

Take note of the differences between the normal and sick newborn codes (99460-99465, Initial hospital or birthing center care, …) to improve your newborn coding skills.

Think of Normal Newborn as Having No Health Issues

You’ll report a normal newborn’s initial E/M encounter with 99460-99463. 

“A normal newborn is one who does not need additional care for a diagnosis other than birth,” says Charlotte T. Tweed, RHIA, CPC, coding auditor, GME interim compliance manager/privacy officer and certified ICD-10 instructor at the Florida Hospital Graduate Medical Education Department of Coding & Auditing in Orlando. 

“The exception would be mild jaundice that does not require photo therapy,” elaborates Tweed. “Without photo therapy the newborn with that diagnosis would still be called normal. With photo therapy you would move to the initial hospital [care codes (99221-99223)].” In this case you would use the initial hospital care codes because the newborn has a diagnosis over and above being born and requires some additional care.

Initial newborn care for a normal infant typically includes a maternal and/or fetal and newborn history; a newborn physical examination; ordering diagnostic tests and treatments; meetings with the family; and documentation in the medical record.

Coding tip: Because the 99460-99463 range uses “normal newborn” in the description, the only diagnosis codes you can use from the V30-V39 (Liveborn infants according to the type of birth) diagnosis range are the ones with “liveborn” in their description.

Add-ons: Procedures such as a circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes. These codes have zero day global periods. Be sure to report the circumcision in addition to newborn care. To indicate 99460-99463 is significantly identifiable from the minor E/M included in surgical codes, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to 99460-99463.

Check Out the Coding Choices For a Sick Newborn

When your physician provides E/M services for a “sick” newborn, you’ll choose from the following codes:

• 99464 (Attendance at delivery [when requested by the delivering physician or other qualified health care professional] and initial stabilization of newborn)
• 99465 (Delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output)
• 99221-99223 (Initial hospital care …)
• 99468-99469 (Initial inpatient neonatal critical care, …) 
• 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, ...).
• 99478-99480 ( Subsequent intensive care, per day,…)

A sick newborn may have a fever, high hemoglobin count, or mild respiratory distress, for example.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The physician orders a culture and initiates IV antibiotics for the newborn. You will report services for the initial day of the sick newborn’s care with the appropriate choice from the 99221-99223 range.

Don’t Always Bundle Attendance and Resuscitation

Because attending a delivery is included in the relative value units for 99465, you should not report 99464 and 99465 during the same session. 

You would use 99465 when no secondary physician is requested to assist the delivery. 

CPT® 99465 pays almost twice what 99464 pays. But if your physician is asked to attend a delivery because of unexpected complications and he doesn’t provide resuscitation, 99464 is the most appropriate code choice.