Primary Care Coding Alert

Question:  In our FP’s office, a newborn is seen as a quick assessment within a few days of birth at no charge. The mother returns with the baby at 2 weeks for an exam. Should this be an E/M and should it be established or new?

Virginia Subscriber

Answer: The first thing to determine is whether the newborn is a new or established patient. Per CPT®, a new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years. In CPT® parlance, “professional services” are those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services and reported by a specific CPT® code(s).

According to your question, the FP previously saw the newborn for a quick assessment but did not report a specific CPT® code for the encounter. Assuming the FP has not provided any other professional services to the newborn and that another FP in your group has also not provided any professional services to the newborn, you may technically consider the patient as “new” when seen at two weeks. However, this technical distinction is unlikely to be readily apparent to the parents, who will probably think of the newborn as “established,” since the FP actually saw and assessed the baby previously. Thus, for the sake of ongoing patient relations, you may want to consider the child as “established” when reporting the encounter at two weeks. 

Thus, if no feeding or other health problem has been previously noted, you may consider this two week visit as the first well child visit when provided by a physician, nurse practitioner or physician assistant. You can report the CPT® code 99391 (Periodic comprehensive preventive medicine reevaluation 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, established patient; infant [age younger than 1 year]) with diagnosis code V20.32 (Health supervision for newborn 8 to 28 days old) for this service, if you consider the child to be an established patient. The corresponding code for a new patient is 99381.

This service includes time spent addressing routine feeding issues. However, if significant time beyond that typical of the infant preventive service is spent addressing a problem or in problem-oriented counseling, you may also report a problem-oriented service (e.g. 99212-99215 for an established patient) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to indicate that significant and separately identifiable evaluation and management services were provided on the same date. 

Documentation should include approximate time spent face-to-face with the family and patient, notation of time spent in counseling and context of counseling. You may select the problem-oriented code based on time spent in counseling and coordination of care when documentation indicates more than 50% of face-to-face time associated with the problem-oriented code was spent in these activities. In this scenario, you may need to document how much of the total time spent face-to-face with the patient was for the preventive service and how much was associated with the problem-oriented service. 

Note: When the visit is in follow-up to an identified problem such as jaundice, infrequent stools, or infrequent feedings, and the physician, nurse practitioner, or physician assistant provides the service, only an office visit (e.g., 99212-99215) and problem specific diagnosis codes should be reported.