Pediatric Coding Alert

Question: Our pediatrician saw a newborn in the hospital on day 1 and excised a cyst from the newborn's fifth digit. He also attended to the baby on day 2 prior to discharge. What is the appropriate way to bill for these services?

California Subscriber

Answer: Your pediatrician should report an E/M service per day and the procedure. For the newborn's initial examination, you should report 99431 (History and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records [this code should also be used for birthing room deliveries]). Although the patient has a cyst on his finger, he is still considered a normal newborn.

For the cyst removal, select the appropriate code based on the method the physician employed. If he shaved the skin lesion, use 11305*-11308 (Shaving of epidermal or dermal lesion, single lesion, scalp, neck, hands, feet, genitalia ...), depending on the lesion's diameter. Note: CPT defines shaving as "sharp removal by transverse incision or horizontal slicing to remove epidermal and dermal lesions without a full-thickness dermal excision."

If the doctor made a full-thickness (through the dermis) excision, assign 11420-11426 (Excision, benign lesion including margins, except skin tag [unless listed elsewhere], scalp, neck, hands, feet, genitalia ...). You may report 99431 and 11xxx on the same day. Make sure you append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99431 to designate a separately, identifiable E/M service from the lesion removal.

Finally, on the discharge day, report 99238 (Hospital discharge day management; 30 minutes or less) or 99239 ( more than 30 minutes). CPT allows reporting only one E/M code per day. So, the pediatrician may not separately bill for his attendance on day 2.