Pediatric Coding Alert

In the February issue of PCA, we discussed the use of 99432 (normal newborn care in other than hospital or birthing room setting). Some pediatric practices are using this code inappropriately. It pays better than CPT 99391 (the preventive care services code for children under one year), but we said in the story that 99432 is to be used when a pediatrician travels to a home or a birthing center to examine a newborn. However, there are circumstances under which the code is used for services provided in the pediatricians office, as well.

Code 99432 is the only code you can use when a baby was born in a home, then brought to your office for the first exam. This is a fairly frequent occurrence at Baylor Pediatric Center, a three-physician, one-nurse practitioner practice in Dallas, TX. Her pediatricians use 99432 when a mother delivers at home or at a birthing center, says Jennifer Bell, practice administrator, and brings the baby to the office within the first hours of life for the newborn exam. This is the only time Bell uses 99432 for an office visit. The pediatrician performs the same type of exam that would be performed in the hospital, says Bell. The pediatrician does not need to travel to the birthing center or home in order to use this code.

In fact, CPT states that 99432 is for normal newborn care in other than hospital or birthing room setting, including physical examination of baby and conference(s) with parent(s). It doesnt say that the pediatrician has to travel to the place where the baby was born.

This is the real purpose of 99432, says Kim Rockwell, ART, CCS, CCS-P, the coding auditor for Bells group. Codes 99431 and 99432 are complementary codes, she says. While 99431 is for normal newborn care in the hospitalthe description specifically refers to the preparation of hospital records99432 is for normal newborn care for babies born elsewhere, says Rockwell. If the baby is born at home and the parents bring it to the pediatricians office, 99432 is the best code to use, she says. The pediatrician doesnt have to go to the home to use that code.

However, Rockwell acknowledges that the fee difference between 99431 and 99432 (99432 reimburses higher) is probably due to the fact that there is a greater chance that the pediatrician would have to go to the baby. If the baby were born at home, its possible that the mom wouldnt want to go out right away, and the parents might request that the pediatrician come to them, she says.

The diagnosis code for the baby born at home would be V30.20. The fourth digit (2) indicates that the baby was born outside hospital and not hospitalized, and the fifth digit (0) indicates that the baby was born vaginally.

The 48-Hour Rule

The reason that some practices were using 99432 for the first office visit of babies who were born in the hospital is because of managed care, which is pushing to get babies discharged within 48 hours of birth. Since pediatricians no longer have several days to tend to a baby in the hospital, the first office visit requires more work; problems that may have developed and been easy to treat in the hospital now need to be handled on an outpatient basis, at least in the examination. So some practices have been trying to recoup on that extra work by coding 99432 for the first office visit, but this is incorrect.

The First Office Visit

Bells practice does see babies two days after discharge, however, and uses the preventive medicineservices codes for that visit (99391, if the baby was seen by the practice for the newborn exam, or 99381, if the baby was not seen by the practice for the newborn exam but rather was seen by another pediatrician).

Melinda Carver, office manager for Coffee County Pediatrics, a solo practice in Douglas, GA, bills for a regular office visit (99212-99215 for established patients; 99201-99205 for new patients) for babies who come in during the first few days after birth. Most babies who come in that early come in with colic or jaundice, so it is a sick visit, says Carver. For the scheduled visit, thats usually a week to 10 days after discharge, and we use the preventive-care code.

Along with the advent of the 48-hour discharge, pediatricians and parents of newborns are dealing with some insurance rules that require home health care instead of going to the pediatrician or the hospital. For example, some Medicaid programs do have health department nurses go into the home to check on a babys feeding. Pediatricians generally get a very low monthly fee from Medicaid (we have heard this is $3 to $5 in many parts of the country) to coordinate this care; from a reimbursement standpoint, seeing the baby in the office is preferable.

Sometimes parents want to bring a baby in sooner than a week after discharge. They may just want to have the baby examined for their peace of mind. If the parents want to see us, thats fine, says Carver. They know they have to pay their co-pay; we use the preventive-care codes under those circumstances.

Whether to use the preventive-care codes for the first newborn visit is an issue, because most managed care plans dont allow you to use 99391 more than a certain number of times. We use 99391 for the first visit one to two weeks after discharge, says Delores Butler, office manager for Cumberland Pediatrics, a two-pediatrician practice in Smyrna, GA. We have no problems getting paid for it, even from Medicaid. Butler notes that the practice doesnt have any hospital records by this first routine visit, so the chart must be started from scratch. The diagnosis code she uses for this first visit is V30.0 for a newborn born vaginally.

A key point to remember is that the 12-month visit often gets denied because too many well-care visits have been used in the first year. This varies from plan to plan, and each states Medicaid program is different as well. This is why Thomas Kent, CMM, principal of Kent Medical Management, a medical practice consulting firm in Dunkirk, MD, recommends that all visits prior to the two-week visit should be coded as 99212-99215 instead of the preventive-care codes. If the child has an illness, then use that diagnosis code, says Kent. If the child is well, use V20.8, since the physician is observing for possible jaundice.

The Basic Codes

Here are the different codes you can use for the newborns first exam when you see the baby in your office, and not in the hospital.

99432: History and exam of the normal newborn who is not born in the hospital. This code is for the very first visit after the baby is born; perhaps the baby was born at home and the parents brought him or her to your office. You would also use this code if you traveled to the place of birth for the exam. The code also covers any conferences you have with the parents.

99381: Initial preventive-medicine visit in the office for a new patientone your practice has never seen before in the office or in the hospital. This is for a routine visit, not a sick visit such as colic or jaundice.

99391: Periodic preventive medicine in the office for an established patient. Again, this is a routine visit, not a sick visit.

99212-99215: Office visit for a newborn with some type of a problem, or for a newborn whom the parents are concerned about.