Primary Care Coding Alert

Hint: Use new patient or established codes depending on previous review of the infant.

When your FP sees a newborn child following discharge from the hospital, you’ll need to consider patient status, timing of the visit, and any medical conditions from which the child is suffering to determine whether to report the visit with a “well visit” or a “problem-oriented visit” code.

Consider Timing to Clue in on Purpose of Visit

If your FP is seeing the child two weeks after hospital discharge, he is most likely seeing the child for a “well visit.” In this case, you’ll have to report the most appropriate code depending on the patient status. So, you’ll report the visit with 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant [age younger than 1 year]) or with 99391 (Periodic comprehensive preventive medicine reevaluation and management…established patient; infant [age younger than 1 year]), depending on if your FP is seeing the child for the first time or has evaluated the child before.

When the infant is seen by your FP earlier than two weeks after hospital discharge, it is more likely that he is evaluating the child for some medical issues. If that’s the case, you cannot report a well visit and should consider the session as problem-oriented and report it with an appropriate E/M code.

Coder tip: Review the encounter notes to get clues on whether to report a “well visit” or a “problem-oriented visit.” If you see in the documentation that your FP made notes regarding the child’s weight, height, immunization status, and development stages, you can probably safely report a well-visit using 99381/ 99391. Instead, if you see documentation mentioning weight loss, feeding problems, colic, jaundice and such, you’ll have to report a problem-oriented visit.

Example1: Your FP sees an infant that was discharged from your hospital two weeks prior. Your FP’s documentation of the encounter mentions the infant’s weight at 7.5lbs (3.4 kg); length of the child as 22 inches and head circumference of 14 inches. He mentions that vision and hearing appears normal and physical examination detected no abnormalities and the child appears to be developing normally. Since you see no documentation of any abnormalities or see any feeding problems, you will report this visit using 99391 (you use an established patient code as the child was discharged from your hospital).

Determine Patient Status to Report Appropriate E/M Code

In case your FP is seeing the child for a medical issue, you’ll have to report with an appropriate E/M code. To arrive at the correct E/M code to report for the session, you’ll need to determine whether to report an established patient code or a new patient visit code.

In case your FP or another physician/qualified health care professional in the same group practice has provided a professional service to the child, you’ll report an established patient code for the problem-oriented visit from the code range 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient…).

If the child is being evaluated for the first time by your FP and no other physician/qualified health care professional in your practice has provided a professional service to the child previously, you’ll report an appropriate new patient code from the range 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient…), depending on the other factors (e.g. history, examination, and medical decision making) used to determine the level of the code.

“In either case, CPT^® defines a ‘professional service’ as a face-to-face service with its own CPT^® code,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Example 2: Your FP reviews an infant who has been discharged two weeks prior from a hospital in another state. The infant’s mother tells that the child was born over there as she went into labor when she went to visit her ailing mother. She returned back after the child and she were discharged from the hospital. She complained that the child was crying continuously and not feeding properly. Suspecting colic, your FP performs a detailed examination to check for signs of intestinal obstruction, infection of the GI tract, and performs an eye and ear examination to check for sings of any infection. He also goes over the feeding cycles with the mother to check if the baby is being overfed. Since the child was seen by your FP for a specific problem, you’ll report the encounter with new patient E/M codes 99203 for this encounter (as the child was seen for the first time).

Support E/M Code With Diagnosis

When your FP is evaluating a newborn for a medical issue or following up on a previously encountered medical problem, you’ll have to support the E/M code that you are reporting for the visit with diagnosis codes that tell the payer why your clinician was seeing the patient. Your documentation will not be complete and the payer might deny payments if the E/M code that you’re reporting is not supported by the appropriate diagnosis codes.

For example, if your FP is evaluating the child for feeding problems, you’ll have to report the diagnosis code, 779.31 (Feeding problems in newborn) to the E/M code that you’re reporting for the session.

Caveat: In case the medical issue for which your FP is seeing the patient has resolved since the previous encounter, you should report a diagnosis that reflects the follow-up nature of the encounter. For instance during a hospital visit, your FP suspected the child to be suffering from jaundice and wanted to review the child after discharge. In the subsequent session in the office, he finds no jaundice. In that case, you’ll report V67.9 (Unspecified follow-up examination). Since your FP had reviewed the child in the hospital, you’ll report an established office E/M code such as 99213 to report the encounter

“Do not report 774.6 (Unspecified fetal and neonatal jaundice) as the diagnosis code to support the E/M code you’re reporting for the session, because it implies that the child still has jaundice,” advises Moore. “ICD-9 coding guidelines advise not coding diagnoses considered to be ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working’ diagnoses,” Moore notes.

In such a scenario, an alternative is to use the V code, V29.8 (Observation and evaluation of newborns and infants for suspected condition not found; Observation for other specified suspected conditions) that lets the payer know that your FP evaluated the infant for a possible condition, which was not found upon examination.

Add V Code to Well Visit

When your FP sees the infant for a well-visit, don’t forget to use the V code, V20.2 (Routine infant or child health check) along with 99381/ 99391. You should not use V20.2 if the purpose of the visit is problem-oriented, as the payer will deny your claim. Reserve the use of this V code for a preventive visit when the child is not suffering from any kind of medical issues.

So, in example 1 illustrated before, you can report 99391 with V20.2 while in example 2, you cannot report this V code. If during a succeeding visit, if your FP reviews the child again for colic and found no instance of the condition, you can report the appropriate established patient E/M code for the encounter and report V29.8 to let the payer know that the child was being reviewed for colic but is not found in this session.