Primary Care Coding Alert

According to the American Academy of Family Physicians (AAFP), more than 60 percent of their members report they provide newborn care immediately following delivery and that they follow up with these young patients in the ensuing days and weeks. Several codes are used to report the care provided, according to Beth Kluge, CPC, supervisor of medical coding and education for Mercy Health Systems in Janesville, Wis.
 
Note: In some cases, the FP will personally deliver the child. These services are usually covered by the global package assigned for maternity care if the physician cared for the patient throughout her pregnancy (e.g., 59400, routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps] and postpartum care). For more information, see Ob-Gyn Coding Alert Volume 2, No. 7, July 1999.

    
Sometimes an obstetrician has provided the maternity care but the FP is asked to attend  an abnormal birth (e.g., premature delivery, multiple births, etc.). "This often occurs when the mother has decided that the FP will become the child's primary physician," Kluge explains. "The OB then might ask the FP to attend. As with other consultations, the delivering physician must directly request that the other physician be in attendance in order to bill the consult codes."
    
When this is documented, the FP's services are reported with 99436 (attendance at delivery [when requested by delivering physician] and initial stabilization of newborn). Among the services the FP provides at delivery are initial assessments like Apgar testing and suctioning the airway if the child respirated meconium. These services are included in 99436. 
    
If the child has significant cardiac or pulmonary problems immediately after birth, the delivering physician will often call on a neonatologist or pediatrician. The FP may be required to resuscitate a newborn in distress. This is reported with 99440 (newborn resuscitation: provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output). This CPT code would be used instead of 99436; you cannot bill both.
    
On occasion, family physicians may be asked to assist during a cesarean delivery. This would be assigned the appropriate code (e.g., 59514, cesarean delivery only), appended with modifier -80 (assistant surgeon).

Care for Healthy Newborn

   
CPT provides specific codes for the care of a healthy newborn, Kluge says. "When reporting the initial assessment, family practice coders would assign 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]). Unlike the initial hospital care codes that would be assigned for adults (99221-99223), there is only a single code for normal newborns. CPT doesn't offer different codes to represent different levels of service."
 
Although it is rarely used, Kluge says a second code is assigned when a child is born outside of a hospital or birthing center, such as at home. If this occurs, 99432 (normal newborn care in other than hospital or birthing-room setting, including physical examination of baby and conference[s] with parent[s]) would be assigned instead of 99431.
 
Subsequent hospital care provided to the normal infant is reported with 99433 (subsequent hospital care, for the evaluation and management of a normal newborn, per day). Like 99431, there is only one level of service available to describe this care. 99433 may be reported once for each date the baby is in the hospital, except for the date of discharge. Coders would assign 99238 (hospital discharge day management; 30 minutes or less) or 99239 (... more than 30 minutes) for newborn hospital discharge services provided on any date after the admission date.
 
Previously, many insurance companies would pay for only 24 hours of infant and maternity care. When a newborn is admitted and discharged on the same day, code 99435 is assigned (history and examination of the normal newborn infant, including the preparation of medical records). A note following the description clearly outlines circumstances when this code should be assigned.  
   
"This was a code we used quite a bit a few years ago," says Cynthia DeVries, RN, CPC, coding and reimbursement specialist with Lee Physicians, a 140-physician practice in Ft. Myers, Fla. "Fortunately, several professional organizations worked with the insurance industry to change the one-day limit. Many health problems in newborns aren't easily spotted within 24 hours. It usually takes another day. Most payers now allow two days of hospitalization, which is a great improvement."
 
On those rare occasions when the child is discharged earlier than two days after birth, the family physician will usually see the newborn in the office when it is 48 hours old for a PKU (phenylketonuria) test. Coders would report a preventive-service code (i.e., either 99381, initial preventive medicine, new patient; infant [age under 1 year], or 99391, periodic preventive medicine, established patient; infant [age under 1 year]), along with the code for the heel stick (36415, routine venipuncture or finger/heel/ear stick for collection of specimen[s]) and PKU, if the physician's office performed the lab test (i.e., 84030, Phenylalanine (PKU), blood).

 
When a child is born with certain health problems, coding for hospital admission and care will change, DeVries says. "Coders would then assign codes from the sections generally used for adults (i.e., 99221-99223 for initial care and 99231-99233 for subsequent care). Practices would report the level of service as documented in the patient record."
 
It's important to link diagnosis codes in these instances, she adds. "Most typically, a FP physician would encounter problems like heart murmurs (e.g., 785.2, undiagnosed cardiac murmurs), hip dislocations (835.00, dislocation of hip; closed dislocation; unspecified), collarbone fracture (767.2, birth trauma, fracture of clavicle) or jaundice (774.6, unspecified fetal and neonatal jaundice)." Critical illnesses or conditions are usually referred to other specialists like neonatologists or pediatricians.

 
Family physicians may also provide additional services shortly after the birth of a child. DeVries says some services may be reported separately.
 
"If the parents choose to have a son circumcised, for example, this would be coded and billed in addition to any delivery and hospitalization services," she says. Depending on the technique used, coders would assign 54150 (circumcision, using clamp or other device; newborn) or 54160 (circumcision, surgical excision other than clamp, device or dorsal slit; newborn).
 
Note: Coverage for newborn care differs from payer to payer. Coding professionals should check with each medical director to determine policies about billing these services.