Primary Care Coding Alert

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 [...]