Primary Care Coding Alert

Pediatric Coding Corner:

4 Field-Tested Tips for Improving Newborn Exam Payment

Published on Mon Sep 15, 2003

When your FP evaluates a newborn after a hospital discharge, consider the visit a problem-oriented visit - not a well visit - and you'll ethically optimize your practice's pay.

Reporting 99381/99391 (Preventive medicine service) instead of 99201-99215 (Office or other outpatient services) for a newborn follow-up visit will sacrifice one of the child's allotted preventive medicine services, creating future reimbursement problems, says Melissa Parker, CPC, a family-practice billing specialist at Family Wellness Center in Vancouver, Wash. But how do you know whether the visit is problematic or preventive and if the newborn qualifies as a new or established patient?

Coding experts offer four tips on choosing the right CPT code, as well as the diagnosis necessary to get newborn visits paid.

1. Practice Relationship Determines Patient Status

If an FP in your practice treated the newborn in the hospital, you should report an established patient office visit (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient; or 99391, Periodic comprehensive preventive medicine reevaluation and management of an individual ... established patient; infant [age under 1 year]) - even if this is the infant's first visit to your office, Parker says.

For encounters involving infants that no FP in your practice has cared for, you should use a new patient E/M code (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient; or 99381, Initial comprehensive preventive medicine evaluation and management of an individual ... new patient; infant [age under 1 year]).

2. Timing Signals Sick or Well

When an FP evaluates an infant for a medical concern a few days rather than two weeks after hospital discharge, you should report a problem-oriented visit (usually 99212-99213 depending on the visit's extent), Parker says. If you're not sure whether the newborn encounter is for a sick or well visit, here are two ways to find out:

Check the infant's age: If the FP sees the newborn a few days after discharge, the visit is probably for a medical problem evaluation. Bill a problem-oriented visit (99201-99215). On the other hand, 2-week-old infants require a health check. In this case, you should typically report a preventive medicine service (99381 or 99391).

Look at the FP's procedures: Notes that include height and weight checks, immunizations, addressing health concerns and development stages signal a well check (99381, 99391). Documenting feeding problems, weight loss or jaundice indicates a problem-oriented visit (99201-99215).

3. Explain Follow-Up Visits

To support a sick-visit claim, you should use a diagnosis code that reflects the infant's problems. For instance, if the newborn is losing weight, you should assign 783.21 (Symptoms concerning nutrition, metabolism, and development; abnormal loss of weight and underweight; loss of weight). If the FP treats the baby for jaundice, use 774.6 (Other perinatal jaundice; unspecified fetal and neonatal jaundice). For feeding problems, use 779.3 (Other and ill-defined conditions originating in the perinatal period; feeding problems in newborn).

As long as a medical problem prompted the encounter, you should use a diagnosis code that reflects the FP's reason for seeing the infant. For example, in the hospital the baby might have lost weight but might have gained weight by the four-day visit in your office. You should still report feeding problems (779.3) because that concern prompted the visit. Suppose the FP in the hospital suspected that the infant had jaundice, but when he sees the baby at three days of age, the child no longer has jaundice. You should still bill for jaundice (774.6).

If the newborn is no longer sick at the visit, you should also use a V code to indicate that upon examination the FP did not find the problem that he suspected, says Jeffrey Linzer Sr., MD, FAAP, MICP, representative to the ICD-9-CM editorial advisory board. For instance, during an H&P in the hospital, an FP suspects that a baby has colic. When the mother brings the baby in two days later, the FP finds no evidence of colic. You should report 789.0x (Other symptoms involving abdomen and pelvis; abdominal pain) as the primary diagnosis code, followed by V29.8 (Observation and evaluation of newborns and infants for suspected condition not found; observation for other specified suspected condition). This coding combination indicates that the FP saw the child to rule out colic, he says.

4. Reserve V20.2 for Well Visit

Don't use a routine infant checkup diagnosis (V20.2, Routine infant or child health check) for a follow-up office visit, says Kimberly J. Engel, CPC, primary-care biller at Infinity Healthcare in Milwaukee. Because the ICD-9 descriptor contradicts the sick-visit code, the payer will probably deny the claim. You should instead use V20.2 when the FP performs the infant's two-week well check and no illness is present, Engel says.