Pediatric Coding Alert

Question: If I report 99431 and 99433 to Blue Cross Blue Shield of Illinois for a normal newborn with physiologic jaundice, the insurer denies the claim based on CPT and ICD-9 code incompatibility. Should I use 99223 and 99233 instead, or different codes?

Illinois Subscriber

Answer: Coding experts disagree concerning whether a newborn who has jaundice (774.6, Unspecified fetal and neonatal jaundice) qualifies for the normal newborn codes (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]; and 99433, Subsequent hospital care, for the evaluation and management of a normal newborn, per day). Most pediatricians agree that unless the jaundice requires extra physician work or a transfer to an intermediary nursery, you should still use 99431 and 99433. In your case, typical physiologic jaundice does not usually require additional work. Therefore, these codes seem appropriate from a clinical standpoint.

The payer, however, is not privy to this ambiguity. It instead perceives a newborn with jaundice as abnormal. Consequently, it requires the hospital care codes (99221-99223, Initial hospital care, per day, for the evaluation and management of a patient ; 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ). Local medical review policies supersede coding conventions. Therefore, you may follow the insurer's guidelines. But, because these local variations contradict normal rules, you should obtain the policies in writing to protect yourself in the event of an audit.

Another reason Blue Cross Blue Shield may deny the claims is that you failed to shift code subsections from the first to a subsequent day. Because jaundice does not typically surface until the second day, the pediatrician would treat a normal newborn on the first day. So, on day 1, you should report 99431. If the patient then requires additional treatment, such as phototherapy, you should switch to 9923x.