EM Coding Alert

Question: One of our pediatric physicians saw a newborn at the hospital with no medical conditions or need for special care. The history and examination were normal. She did perform a circumcision at the hospital that was determined at the visit. What would I code with what diagnosis code?

Ohio Subscriber

Answer: You will report a normal newborn’s history and examination with 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn) with modifier 57 (Decision for surgery) attached. This code includes a monitoring nourishment of the newborn, reviewing records of vital signs, and evaluating weight gain or loss, bowel and bladder function, and sleeping patterns.

Consider reporting V30.xx (Single liveborn) as your diagnosis code and 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]) for the circumcision.