Pediatric Coding Alert

When evaluating a newborn after a hospital discharge, don't fall into the trap of coding a well visit consider the visit a follow-up hospital visit and you'll ethically optimize your practice's reimbursement.

Remember, if you or others from your practice provided newborn care, the infant is considered an established patient even on its first visit to your office.

If the baby has minor problems at the visit, you should bill a "sick visit" (99212-99215, Established patient office visit) with the proper diagnosis codes, says Richard A. Molteni, FAAP, medical director of Children's Hospital and Regional Medical Center in Seattle. Select a diagnosis code that reflects any problems the baby might have. For example, if the baby is losing weight, use 783.21 (Loss of weight). If the baby has jaundice that requires treatment, assign 774.6 (Unspecified fetal and neonatal jaundice). For feeding problems, you can assign 779.3 (Feeding problems in newborn). Code this visit 99213 or 99214.

If the baby is well at the visit, use a diagnosis code that reflects your reason for wanting to see the baby. For example, in the hospital the baby might have lost weight, but might have gained weight by the four-day visit in your office. You can still code feeding problems (779.3), because that concern prompted the visit. Or you might have been concerned about possible jaundice, but when you see the baby at four days of age the jaundice had resolved. You can still bill for jaundice (774.6), Molteni says. CPT codes for these visits would likely be 99212 or 99213.

Because of heightened medical risk when the patient is a newborn, rule-out codes and V codes can sometimes be used. The V29.x series represents observation for a suspected condition in a newborn, says Jeffrey Linzer Sr., MD, FAAP, MICP, Academy of Pediatrics representative to the ICD-9-CM editorial advisory board. Coupled with a diagnosis code, V29.x (Observation and evaluation of newborns and infants for suspected condition not found) can signify that the physician is concerned about a problem but did not find it upon examination, says Linzer, also a professor of pediatrics at Emory University in Atlanta. In a baby in whom colic is a concern but not found, for example, use 789.0x (Abdominal pain) as the primary diagnosis code, followed by V29.x. This coding combination shows that the pediatrician saw the child to rule out colic.

The pediatrician sometimes just wants to weigh the infant on a three- or four-day visit. The nurse weighs the baby, and if the weight has increased, notes it and sends him or her home. You should bill 99211 only, with 779.3 (Feeding problems in newborn). Do not bill a higher-level E/M unless the pediatrician can justify the higher level with two of the three E/M service elements (history, examination, medical decision-making).

The nurse should do more than weigh the infant to support a 99211 E/M code. She should document factors such as family adjustment, infant temperament and interval feeding history.

For circumcision performed in the office, you should bill 54150 (Circumcision, using clamp or other device; newborn). You should report any additional and separate work with an office visit code appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service).

Suppose a child who lost weight in the hospital is brought in three days after discharge for a weight check, examination and circumcision. For the examination, you should assign 99212-25 linked to diagnosis code 783.21 (Loss of weight). For the circumcision, report 54150 with a diagnosis of V50.2 (Routine or ritual circumcision).

Note: Some providers have found using modifier -59 (Distinct procedural service) on the circumcision without modifier -25 on the E/M code is an effective way to have both services reimbursed.

If you perform a phenylketonuria (PKU) screen, you should assign 36415* (Routine venipuncture or finger/ heel/ear stick for collection of specimen[s]). You should also report an office visit, even if only a nurse visit (99211), but document some separate and distinct E/M services. Code 36415* is a starred procedure, which means the code includes the procedure only. When you report a starred procedure and an E/M visit, CPT now requires modifier -25 on the E/M visit. However, some payers have not adopted CPT's rule and allow billing both procedures without a modifier. Therefore, you need to know the payer's policy.

For the diagnosis code, report V77.3 (Special screening for endocrine, nutritional, metabolic, and immunity disorders; phenylketonuria [PKU]). Do not use 270.1 (Phenylketonuria), which would indicate that the child has PKU.

If the state lab charges you for the test kit and you pass the cost on to the insurance company, bill 84030 (Phenylalanine [PKU], blood) appended with modifier -90 (Reference [outside] laboratory).

Inform your staff that these early visits are "follow-up hospital visits" and not well visits and that the visits should be coded as office visits, not preventive medicine (99391, Periodic comprehensive preventive medicine reevaluation and management of an individual including an age- and a gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; infant [age under one year]). If you report a preventive medicine service, the patient's health plan will count the visit as one of the child's allotted number of annual visits.

In addition, do not use a routine infant checkup diagnosis (V20.2, Routine infant or child health check). The description contradicts the sick visit code, which will probably result in payer denial.