Pediatric Coding Alert

Question: When billing initial newborn visit and hepatitis shot, how can we get paid for both services? Should we bill with modifier -25 (significant, separately identifiable evaluation and management [E/M] service by the same physician on the same day of the procedure or other service) using codes 99432 (normal newborn care in other than hospital or birthing room setting, including physical examination of baby and conference[s] with parent[s]) and 90744 (hepatitis B vaccine, pediatric/adolescent dosage, for intramuscular use)?

Calvena Winston
Cumberland Pediatrics, Marietta, Ga.

Answer: If you have seen the patient in the hospital, then you may not charge an initial newborn visit (99432). Instead, you should use a well-visit code: 99391 (periodic preventive medicine reevaluation and management of an individual including a comprehensive history, comprehensive examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate laboratory/diagnostic procedures, established patient; infant [age under 1 year]).

But if this visit is the first time you have seen the child, then 99432 or 99381 is correct. The hepatitis shot should be billed using 90744 and an administration code (90471). The documentation in the chart should justify the evaluation and management (E/M) service performed and the immunization given. The best solution is to appeal to the insurance company with a copy of the CPT information and the chart documentation to reprocess the claim.

The bottom line: If the pediatrician is delivering the immunization in the hospital, this is not the best course, some coders believe. The hospital should supply and deliver the immunization because the hospital can deliver this service and be paid for it without difficulty.

Answers to You Be the Coder and Reader Questions provided by Richard H. Tuck, MD, FAAP, founding chair, American Academy of Pediatrics' committee on coding and reimbursement; Mark S. Reuben, MD, FAAP, president, Reading Pediatrics, Wyomissing, Pa.; Victoria Jackson, chair, pediatric task force committee, MGMA; Thomas Kent, CMM, president, Kent Medical Management; Richard A. Molteni, MD, FAAP, CPT editorial panel, vice president and medical director of Children's Hospital and Regional Medical Center in Seattle, Wash.