Pediatric Coding Alert

Question: The August 2005 Pediatric Coding Alert suggests coding an additional E/M service when a newborn's status changes on the same day as a well newborn admission. How should I code if the neonate's status changes immediately after admission? Should I report just the hospital admission (99221-99223) or the initial neonate critical care (99295) depending on the patient's condition? Or should I assign two separate charges of initial well newborn, plus the hospital round?


Washington Subscriber
Answer: The answer depends on whether the pediatrician performs the initial normal newborn exam (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]) prior to the newborn's status change.

If the pediatrician evaluates and assesses the newborn initially when the child is normal and then later on the same day sees the newborn again to address a neonate who is now ill, you should report both E/M services (such as 99431 and 99231-99233, Subsequent hospital care, per day, for the evaluation and management of a patient ...).
 
If the newborn in the second direct pediatrician-patient encounter is critically ill, you should use 99431 and 99295 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or less). Documentation in these cases should reflect two services.

If, on the other hand, the pediatrician does not perform the initial newborn exam until the infant's status has changed (for instance, the infant was fine on delivery, but the pediatrician had not yet performed the exam), you should report only the "ill" code.

Important: When a pediatrician initially sees a newborn face-to-face who is well and then becomes ill, you should attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the second same-day E/M code. The claim should also contain different ICD-9 codes to support the services.

Possible codes include:

• First visit--99431

• Second modifier 25 appended visit for:

--changed infant condition--99232, 99233 with neonatal hypoglycemia, 775.6

--or neonatal critical care--99295 with respiratory failure of newborn, 770.84.