Pediatric Coding Alert

Question: We almost always report normal newborn care codes for the pediatrician’s visits to the hospital to see newborn infants. But there are times when we’ve leaned toward the hospital codes for sick patients instead. What is the threshold between reporting normal newborn codes vs. sick child codes?

Answer: A “normal” newborn has no abnormal medical conditions or need for special care. Report a normal newborn’s history and examination with a code from the 99460- 99463 series (…Evaluation and management of normal newborn infant).

Initial newborn care for a normal infant typically includes a maternal and/or fetal and newborn history, a newborn physical examination, ordering diagnostic tests and treatments, meetings with the family and documentation in the medical record.

When billing with 99460 for a single newborn, you’ll typically include a diagnosis code from the Z38.xx series (Liveborn infants according to place of birth and type of delivery). For instance, Z38.00 (Single liveborn, born in hospital, delivered vaginally). 

If the baby has other diagnoses, chances are that he doesn’t qualify for normal newborn care. A baby considered a “sick” newborn might have a fever, high hemoglobin count or mild respiratory distress, among other issues. For a sick newborn, you’ll select from the 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) series for the first day of care, based on the level of history, examination, and medical decision making. You’ll then report subsequent hospital visit codes for any remaining days that you see the patient as long as the newborn remains abnormal. If the newborn becomes a normal newborn, switch back to the normal newborn codes for subsequent care: 

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The pediatrician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn’s care with the appropriate choice from the 99221-99223 series. However, if after the first 24 hours the baby is fever-free with no other problems, then bill the subsequent day as 99642.