Pediatric Coding Alert

Question: Our pediatrician was at the hospital for the birth of a normal newborn. While our provider was there, the infant began to show signs of hypothermia, which required observation and interventions along with intensive monitoring. What would be the best way to code this encounter?

Arizona Subscriber

Answer: As the newborn did not present any problems at birth, you would begin 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant). You would also use the corresponding ICD-10-CM code Z38.00 (Single liveborn infant, delivered vaginally) to report the reason for the encounter.

The subsequent critical care would be reported using 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services) with 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) attached to account for the separate service on the same day. And you would document R68.0 (Hypothermia, not associated with low environmental temperature) as the appropriate diagnosis.