newborn visit cpt code

Coding for Newborn Care Services

Newborn care services coding, care of the normal newborn infant.

Evaluation and management (E/M) services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include:

Newborn Care in the Office

After the newborn has been discharged to home, it is common practice to see the infant to assess for jaundice or any feeding problems. Coding for this service depends on the provider of the service and whether the visit is in follow-up to an already identified problem or screening for problems.

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, an office visit (e.g., 99212-99215) and problem specific diagnosis codes should be reported.

If no feeding or other health problem has been previously noted, this visit may be the first well-child visit when provided by a physician, nurse practitioner, or physician assistant. Code 99391 may be reported with diagnosis code Z00.129 (encounter for routine child health examination without abnormal findings) for this service. This service includes time spent addressing routine feeding issues.

However, if significant time beyond that typical of the infant preventive service is spent in counseling, physicians may also report a problem-oriented service (99212-99215) with modifier -25 to indicate the significant and separately identifiable services 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. (Codes may be selected based on time spent in counseling and coordination of care when documentation indicates more than 50% of face-to-face time was spent in these activities.) Diagnosis code Z00.121 (encounter for routine child health examination with abnormal findings) and the appropriate problem diagnosis would be used. If a nurse visit is provided (e.g., weight screen only), code 99211 may be reported. If the nurse visit results in a visit with the physician, only the physician services would be reported. As a family physician, you may also address needs of the mother during a newborn's encounter (e.g., lactation problems). If separately documented in the mother's chart, you may report these services in addition to the services provided to the infant.

Circumcision

Family physicians who perform newborn circumcision should separately report this service. Codes for circumcision procedures include:

Caring for Sick Newborns

When providing E/M services to other than normal newborns, choose the level of care based on the intensity of the service and status of the newborn. Care of newborns who are not normal but do not require intensive services may be reported with codes for initial hospital care (99221-99223). Some infants may require intensive care services but do not meet the CPT definition of critically ill or injured required for reporting of critical care services. (For the definition of critically ill or injured see the Critical Care Services subsection of CPT before codes 99291-99292.) Code 99477 represents initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services. These services include intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the health care team under direct physician supervision. This code may be reported only once per day and by only one physician. Procedures included in the services represented by code 99477 include those listed for the Critical Care Services subsection of CPT (codes 99291 and 99292), as well as additional procedures listed in the Inpatient Neonatal and Pediatric Critical Care subsection (codes 99468-99476, 99466-99467). These include vascular access procedures, airway and ventilation management services, oral or nasogastric tube placement, bladder aspiration or catheterization, and lumbar puncture among others.

Subsequent hospital care of infants who are not critically ill or injured as defined in CPT but who had a very low birth weight and continue to require intensive care services as described for code 99477 above may be reported with codes 99478-99480. Codes 99478-99480 each are described as, "Subsequent intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant" with the code selected based upon the present body weight of the infant as below.

Newborn Critical Care

When the newborn is critically ill or injured, codes exist for reporting of services provided during interfacility transport, initial critical care, and subsequent critical services. Reporting of codes for the services requires careful attention to CPT instructions and when more than one physician is caring for the infant, attention to which physician reports which codes.

Critical Care During Transport

Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24-months of age or less, are reported based on the time of face-to-face care beginning when the physician assumes primary responsibility at the referring hospital/facility and ending when the receiving hospital/facility accepts responsibility for the patient's care. Report code 99466 for 30-74 minutes of hands-on care and code 99467 for each additional 30 minutes of hands-on care. Less than 30 minutes of hands-on care during transport would not be separately reported.

Inpatient Neonatal Critical Care

The initial day of critical care for the evaluation and management of a critically ill neonate, 28-days of age or less, is reported with code 99468. Only one physician may report this code. If another physician provides critical care services to the neonate on the same date, that physician must report the services with critical care service codes 99291-99292. Subsequent days of critical care to the critically ill neonate are reported per day with code 99469. As with the initial critical care, only one physician may report code 99469 on a given date.

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DETERMINING NORMAL VERSUS SICK

The difference in code values, some coding tips for hospital care, newborn care or hospital care.

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American Academy of Pediatrics; Newborn Care or Hospital Care. AAP Pediatric Coding Newsletter September 2016; 11 (12): 1–4. 10.1542/pcco_book149_document001

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Current Procedural Terminology ( CPT ® ) provides specific codes for normal and intensive or critical care of the newborn. In between these levels of care, physicians may report initial or subsequent hospital care for a newborn who is ill but who does not require intensive or critical care. Selecting the appropriate procedure codes for care of the newborn (who has signs or symptoms that may be benign or an indication of illness or congenital defect) requires a decision between care that was significantly beyond normal newborn care and care that was not.

A review of the codes in question may be helpful. First, for the normal newborn, codes are assigned for initial care based on the site of service.

Code 99461 may be appropriate for evaluation and management of a neonate born at home and evaluated in the physician practice soon after birth (eg, same day or next day).

Subsequent care of the normal newborn provided between the date of initial care and hospital discharge is reported with code 99462 . Care on the date of discharge may be reported with hospital discharge day management code 99238 or 99239 except when discharge takes place on the same date as initial newborn care ( 99463 ).

Per CPT , normal newborn care includes maternal and/or fetal and newborn history, newborn physical examination(s), ordering of diagnostic tests and treatments, meeting(s) with the family, and documentation in the medical record.

Initial newborn care of a neonate who is ill but does not require intensive or critical care is reported with initial hospital care codes 99221–99223 . These codes are reported based on the 3 key components of history, examination, and medical decision-making (MDM) or on time spent counseling or coordinating care on the unit or floor. When reporting initial hospital care, documentation must support the specified levels of each of the 3 key components or that more than 50% of the typical unit or floor time assigned to the code was spent in counseling or coordination of care. Physicians may find that documentation to support initial hospital care is more exacting than that for initial care of the normal newborn. Table 1 shows the required key components and typical times for codes 99221–99223 .

Key Components and Documentation of Initial Hospital Care

Abbreviations: HPI, history of present illness; PFSH, past, family, and social history; ROS, review of systems.

Subsequent hospital care services ( 99231–99233 ) are reported for dates after initial hospital care or when the newborn becomes ill after initial normal newborn care. Subsequent hospital care is reported based on 2 of 3 key components (interval history, examination, and MDM) or time spent counseling or coordinating care. The interval history for subsequent hospital care is the history after the physician last performed an evaluation of the patient. This usually consists of the chief complaint, history of present illness (HPI), and problem-pertinent review of systems. No past, family, or social history is required. Table 2 shows the key components and time associated with codes 99231–99233 .

Subsequent hospital care is also reported for the intensive care of a neonate who requires subsequent intensive care (as in codes 99478–99480 ) but weighs more than 5,000 grams.

For all services provided by the attending physician during the birth admission, the first-listed International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ) code will be for a live newborn (eg, Z38.00 , single liveborn infant, born in hospital, delivered vaginally). Codes in category Z38 are not reported for services after transfer from the birth facility to a different facility or once a baby is discharged. The Z38 code is reported as primary by the attending provider, regardless of the length of stay. Additional codes may be reported to describe conditions or signs or symptoms addressed even if the service is reported as normal newborn care. Physicians consulted during the birth admission do not report a code from category Z38 but, rather, codes describing the reason for consultation.

Codes for conditions that begin in the period from birth (day 0 [zero]) to 28 days after birth are typically the P codes found in Chapter 16 of the ICD-10-CM tabular list. For congenital malformations, deformations, and chromosomal abnormalities, see Chapter 17 ( Q codes). Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization. In addition, for newborns only, assign codes that have been specified by the physician or other provider as having implications for future health care services (eg, heart murmur thought to be benign but to be reevaluated after discharge).

When care is provided to a newborn who is well but remains in the hospital pending discharge of the mother, adoption, or other reasons unrelated to illness of the newborn, see code Z76.2 , encounter for health supervision and care of other healthy infant and child.

See the July 2016 AAP Pediatric Coding Newsletter ™ for important ICD-10-CM changes effective October 1, 2016, including new codes for reporting suspected conditions of a newborn that are ruled out after investigation.

Subsequent Hospital Care

Abbreviations: HPI, history of present illness; ROS, review of systems.

Clinical judgment of the nature of the presenting problem determines the choice between reporting as a normal newborn versus initial or subsequent hospital care of the sick newborn. A normal newborn is defined as a newborn who

Transitions to life in the usual manner May include brief period of tachypnea but would not include oxygen beyond the 5-minute Apgar

Requires delivery room intervention but is normal after transition

May require some testing or monitoring (eg, bilirubin, complete blood cell count, culture)

Will not require significant intervention

Is observed for illness but is not sick

Is late preterm but requires no special care

Is in house with sick mother or twin

The sick newborn typically requires an increased level of physician care, nursing observation, and physiological monitoring. A sick visit will have a presenting problem that supports the need for diagnostic investigation or therapy. Therapeutic intervention is typically necessary for the sick newborn. The nature of the presenting problem and extent of work required to diagnose and manage the problem should be considerations when determining the appropriate procedure code to describe the service.

A term newborn is large for gestational age and subsequently monitored for neonatal hypoglycemia. The newborn is asymptomatic. Laboratory testing for blood glucose is ordered 30 minutes after the first feeding. The newborn’s glucose is within acceptable limits and monitoring continues periodically for the first 12 hours. No therapeutic intervention is required.

This service may be reported as initial care of a normal newborn (eg, 99460 ), which does not require specific key components. In this case, the key components necessary for reporting initial hospital care (eg, 4 or more elements of HPI to support a detailed history) may not be met.

A pediatrician is called to the delivery room to examine a 3.8-kg term neonate who has a tumor on the sacrococcygeal spine undetected prior to birth . The neonate is otherwise normal with no distress. On examination, the pediatrician finds a 5-cm mass suspicious for sacrococcygeal teratoma. There are no other abnormal findings. A radiograph of the pelvis is obtained and shows a soft tissue mass of the sacrococcygeal vertebra. The pediatrician consults a neonatal surgeon at a tertiary facility several hours away. Transfer to the surgeon’s facility is arranged. Parents are counseled on the typically benign nature of the tumor, risk of bleeding, and need for complete excision to avoid future malignancy. Total unit/floor time is 80 minutes, with more than half spent in counseling and coordination of care.

Because this neonate is not critically ill and does not require intensive observation and frequent interventions, an initial hospital care code is appropriate. Based on the physician’s documentation that more than 50% of 80 minutes of unit/ floor time was spent in counseling or coordination of care, code 99223 (typical time of 70 minutes) is reported.

Each procedure code is assigned relative value units (RVUs) that are used in calculating payment for services under a fee-for-service payment schedule. Table 3 compares the total facility-based RVUs (includes work, practice expense, and liability) of normal newborn and sick newborn evaluation and management (E/M) services and variance in payment using a conversion factor of $40 per RVU ( example only; actual conversion factors will vary widely). Code 99477 is also included to illustrate the difference between the RVUs assigned for initial intensive care of the newborn versus initial hospital or normal newborn care.

Relative Value Units for Normal Newborn Versus Sick Newborn

Abbreviation: RVU, relative value unit.

As the nature of the presenting problem increases in severity and complexity, so too do the RVUs. Although Table 3 does not include breakdown of RVU components, the increased RVUs are largely due to increased physician work values.

Note that there is little difference in RVUs assigned to normal newborn services and hospital care for presenting problems of low severity or the newborn whose condition is improving. While the RVUs are higher for subsequent care of the normal newborn ( 99462 ) than for subsequent hospital care for a stable or improving condition, CPT ® instructs to report the code that specifically describes the service provided. If the service was predominantly problem focused, report code 99231 . If the service was predominantly focused on normal newborn care (eg, examination, review of orders, anticipatory guidance), report code 99462 . Individual payers may assign different RVUs to code 99462 or limit the number of subsequent normal newborn services.

Note the times in tables 1 and 2 allow for reporting sick visits based on counseling or coordination of care when these activities comprise more than 50% of the unit or floor time. If an initial newborn service includes significant parent or family counseling about the newborn’s condition and treatment options, documentation of the total unit or floor time devoted to the patient and time spent counseling or coordinating care may result in a higher level of service than selection based on the 3 key components. Topics of discussion or coordination activities should always be noted in the documentation in addition to the plan of care.

CPT allows reporting of both services when normal newborn care ( 99460 ) is provided and, later on the same date, the neonate becomes ill and receives subsequent hospital care ( 99231–99233 ), neonatal intensive care ( 99477 ), or critical care ( 99468 ) services by the same physician or a physician of the same specialty and group practice. (Modifier 25 is appended to the code for care of the sick newborn to indicate the separate service.) However, National Correct Coding Initiative (NCCI) edits do not allow payment of normal newborn care on the same date as initial ( 99221–99223 ) or subsequent ( 99231–99233 ) hospital care or neonatal intensive care services ( 99477–99480 ). When a payer contract requires compliance with NCCI edits, report only the highest level of E/M service provided on a single date. Critical care of the newborn is an exception. NCCI edits do allow reporting of neonatal critical care ( 99468 ) on a date when the neonate requires critical care after receiving normal newborn care.

Although subsequent hospital care codes are selected based on meeting 2 of the 3 key components, individual payers may require MDM as 1 of the 2 components used in code selection.

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