Pediatric Coding Alert

Coders are often unsure whether to bill a normal newborn or hospital admission code for a newborn with a minor problem. The normal newborn code (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.]) pays better than the lowest level of the three hospital admission codes (99221-99223), but codes should not be chosen based on reimbursement. If there is a problem even a minor, common one such as jaundice requiring treatment with bili lights the baby is not normal and a hospital code should be used.

The dilemma may continue into subsequent days, when the pediatrician may have to choose between a normal newborn code (99433, subsequent hospital care, for the evaluation and management of a normal newborn, per day) and subsequent hospital care (99231-99233). Again, the question is whether the baby is normal. For example, a baby may be normal at delivery thus warranting 99431 with jaundice developing the second day necessitating a switch to the hospital care codes. If the jaundice decreases by the third day, return to the normal newborn codes, billing 99433.

The test to determine if the baby is normal, according to CPT Codes editorial panel member and vice president and medical director of Childrens Hospital and Regional Medical Center in Seattle, Richard A. Molteni, MD, FAAP, is whether one of two conditions is met:

(1) Is any additional physician work expected? or

(2) Is the baby removed from the mothers room or the normal nursery and admitted to an observation or intermediate-level nursery?

If the answer to either of these questions is yes, do not use normal newborn codes.

In general, both jaundice and an untreated fractured clavicle would qualify as normal, Molteni says. Only if the jaundice exceeds physiological levels and requires treatment and a new diagnosis would the hospital subsequent care codes be used. If the fractured clavicle doesnt call for treatment and it rarely would it, too, would fall in the normal category.

Another gray area (in coding, but not clinical, terms) is a supernumerary digit. The pediatrician treats this by ligation (11200) as a separate procedure, but the baby would definitely still be a normal newborn. An extra finger or toe might not sound normal, but it is when choosing between normal newborn and hospital admission codes.

Two other codes used for newborns 99436 (attendance at delivery) and 99440 (newborn resuscitation) may help determine whether to bill a normal newborn code [...]