Pediatric Coding Alert

Question: What are the documentation requirements for subsequent hospital care (99433) codes?

Ohio Subscriber

Answer: CPT Codes does not define what services are necessary to code 99433 (subsequent hospital care, for the evaluation and management of a normal newborn, per day). Therefore, any documentation that demonstrates the physician delivered services to the newborn on a subsequent day of life is sufficient. You may use a template to check all areas that need to be addressed, such as weight, height, feeding concerns and physical exam. Normally, the hospital has a standard sheet for the healthy newborn.

Remember, however, that 99433 is for a healthy newborn only. If abnormalities or problems are discovered during the visit, use a regular hospital visit (99231-99233) for subsequent care. Documentation requirements for these codes are significantly more stringent than for 99433.