Pediatric Coding Alert

Question: A nurse performs a weight and color check on a newborn whom the pediatrician wanted to see after discharge for suspected jaundice. Which CPT and ICD-9 codes should I use? The nurse notes "No jaundice is found."

Florida Subscriber Answer: Because a clinical reason and documentation exist for the follow-up examination, you should report 99211 (Office or other outpatient visit for the evaluation and management of an established patient ... typically 5 minutes are spent performing or supervising these services) for the nurse's weight and color check.

To explain the reason for the visit, you should use jaundice (774.6, Unspecified fetal and neonatal jaundice) as the primary diagnosis. Even though the baby is well at the visit, the diagnosis reflects why the pediatrician wanted to see the newborn.

To indicate that the condition has resolved, in addition to 774.6 you should report one of two V codes as a secondary diagnosis. Using V67.9 (Unspecified follow-up examination) reflects that the nurse is following-up on a condition. Alternatively, you may report V29.8 (Observation for other specified suspected condition) to reflect that the pediatrician was concerned about jaundice but the nurse found no problems during the examination. Even though the ICD-9 book indicates V29.8 as a primary diagnosis, the notation is for Medicare only.