Pediatric Coding Alert

Report sick visit when baby becomes ill after normal exam

You may be undercoding infant services - unless you capture same-day well and ill visits with two codes.

Fact: You shouldn't automatically roll two same-day E/Ms into one code. This payer-required policy applies only to services involving one diagnosis.

When you provide services involving different diagnoses, you should code each service separately. Practice your skills with this real-world case study.

1 Code or 2? You Decide

Scenario: A pediatrician performs a newborn exam. Later the same day, the baby becomes sick and requires another visit, says Becky Rain, office manager at Alpine Medical Group in Salt Lake City. "My concern is that the insurance company will not pay two E/M codes on the same date of service."

American Academy of Pediatrics (AAP) experts recommend you code the day's encounters using these guidelines.

Step 1: Report Normal Exam With 99431

You should first code the initial normal newborn exam as 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]). The pediatrician does the work involved in a normal exam. Thus, he deserves credit for the encounter.

Step 2: Assign 9923x-25 for Additional Work

When a newborn develops an illness following an initial normal newborn examination, one code may not account for all the work. "The pediatrician must decide whether to report a normal newborn code plus the hospital care or intensive care codes, and whether to use the initial hospital care or subsequent hospital care codes," says Joel Bradley Jr., MD, a pediatrician with Premier Medical Group in Clarksville, Tenn.

In the above scenario, when the newborn becomes ill later in the day, you should report the appropriate-level subsequent hospital care code (99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...). The second E/M code accounts for the additional work the newborn's ill evaluation requires, says Richard H. Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature.

"A physician may charge a newborn exam in addition to a same-day sick visit," Tuck says.

Be careful: Make sure you report a subsequent hospital care code (99231-99233) - not an initial hospital care code (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ...) - for an ill hospital visit following a newborn examination. Because the initial newborn examination constitutes the initial care, the second ill encounter becomes subsequent hospital care.

You should append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to the sick visit. "Just like you use modifier 25 with a significant, separately identifiable service provided at the time of a preventive medicine visit, you would report the ill hospital care code with modifier 25 when provided the same day as a normal newborn exam," Tuck says.

Step 3: Use Different Diagnoses

Make sure you link the correct diagnosis to the appropriate CPT code. Two separate diagnoses will substantiate the medical necessity of both exams and help you appeal any denials.

Example: After a pediatrician performs an initial check for a well newborn, the infant subsequently develops tachypnea, and the pediatrician evaluates the patient's condition.

You code: Report the well exam with 99431 and the ICD-9 gestation codes (such as V30.00, Single liveborn; born in hospital; delivered without mention of cesarean delivery). Link the sick E/M to the patient's illness diagnosis of transient tachypnea of the newborn (770.6, Transitory tachypnea of newborn).

Other possible conditions that could require combination coding include:
 

neonatal jaundice - 774.6, Unspecified fetal and neonatal jaundice
 

neonatal fever - 778.4, Other disturbances of temperature regulation of newborn.