Pediatric Coding Alert

Learn when to use Chapter 16 codes for newborns older than 28 days.

Newborn encounters, like newborns themselves, often come with more questions than answers. Evaluation and management (E/M) services can often turn into more — a single day added to a baby’s age can impact coding, and different situations call for different primary and secondary codes. Even experienced coders sometimes find themselves scratching their heads.

If you can relate, check out these three FAQs we’ve compiled to help you become a top-notch newborn coder.

Question 1: If a newborn encounter begins as an E/M service, but results in a procedure, such as the cauterization of an umbilical granuloma that’s not healing, how should that all be coded?

Answer: In addition to the appropriate E/M code 99202-99215 (Office or other outpatient visit for the evaluation and management of a/an new/established patient …), you’d also report P83.81 (Umbilical granuloma) to go along with 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) for the cauterization procedure.

Note: You would also attach 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 the E/M.

Guideline alert: ICD-10 Chapter 16 (Certain Conditions Originating in the Perinatal Period [P00-P96]) guidelines tell you to use P83.81 (Umbilical granuloma) if the patient is younger than 28 days. This is because “for coding and reporting purposes, the perinatal period is defined as before birth through the 28th day following birth.” If you needed to report the granuloma on its own for a patient 29 days or older, there is a less specific code option, and that’s L92.9 (Granulomatous disorder of the skin and subcutaneous tissue, unspecified).

Coding alert: When coding the scenario in question, however, it would be appropriate to use the Chapter 16 codes even if the patient is older than 28 days, as ICD-10 guideline I.C.16.4 tells you that “should a condition originate in the perinatal period, and continue through the life of the patient, the perinatal code should continue to be used regardless of the patient’s age.” As the granuloma started in the perinatal period, this allows you to use P83.81 no matter how old the patient.

Question 2: If our pediatrician is the one who discharged a newborn from the hospital, then sees the baby again a week later for their first preventive medicine service at the primary pediatric practice, is the child considered new or established?

Answer: Consider this child established. This is because the baby has already received professional, face-to-face services from your pediatrician within the past three years, and those services have presumably been services reported by a specific CPT^® code. Consequently, the child is regarded as established to your practice even though this is the child’s first encounter in your office. This means you will choose 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/ anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)) instead of 99381 (Initial comprehensive preventive medicine evaluation and management of an individual … new patient; infant (age younger than 1 year)).

Remember this new patient advice: “It is a common misconception that place of service [POS] has a bearing on whether a patient is considered new to a practice. It does not. Unless your clinicians are acting in the capacity of different subspecialties when treating the patient, the very first service rendered effectively establishes the patient with your practice,” says Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC. But remember, “payer rules may come into play when defining ‘subspecialty’ in this context,” Blanchard adds.

Question: Do I use Z38.00 or Z00.110 as the primary or the secondary code when the attending physician provided newborn care for a single, vaginally born child?

Answer: This question often causes confusion among coders, but luckily the answer can be found right in the ICD-10 guidelines. Take a look at I.C.21.16, which states that codes from Z38.- (Liveborn infants according to place of birth and type of delivery) can be listed as a principal diagnosis. The guideline goes on to state that “a code from category Z38 is assigned only once, to a newborn at the time of birth. If a newborn is transferred to another institution, a code from category Z38 should not be used at the receiving hospital.”