newborn well visit cpt code

Coding and Reporting Pediatric Preventive Care Services

by Outsource Strategies International. | Published on Aug 17, 2017 | Resources , Medical Coding News (A) | 0 comments

Changes in Medicaid, the Children’s Health Insurance Program (CHIP) and new rules governing employer-sponsored and marketplace insurance plans have improved access to necessary health care for children and young adults over the years. Preventative care protects children against different types of diseases and infections, and allows physicians to monitor and evaluate their physical and mental well-being as they grow and develop. As physicians strive to provide proper preventative care, they can rely on outsourced medical billing and coding services for submitting accurate claims to minimize denials and payment delays, and to indicate that well-care was provided so that quality of care goals can be demonstrated through claims data. Private insurance and Medicaid coverage is available for all age- and gender-appropriate Preventive Medicine visits (Wellness Visits) including all routine immunizations.

The preventive coding guidelines and reporting recommendations of the American Academy of Pediatrics (AAP) are as follows:

Preventive Medicine Service Codes

Preventive medicine service codes are assigned based on whether the patient qualifies as new or established and the patient’s age.

New Patients

For a new patient, initial comprehensive preventive medicine E/M includes:

– age- and gender-appropriate history – physical examination – counseling – anticipatory guidance, or risk factor reduction interventions – ordering of laboratory or diagnostic procedures

The relevant CPT and ICD-10 codes for preventive services for new patients are:

CPT code 99381 – Infant younger than 1 yearICD-10 codes:Z00.110 Health supervision for newborn under 8 days old orZ00.111 Health supervision for newborn 8 to 28 days old orZ00.121 Routine child health exam with abnormal findings orZ00.129 Routine child health exam without abnormal findings
CPT codes: 99382 Early childhood (age 1–4 years) 99383 Late childhood (age 5–11 years) 99384 Adolescent (age 12–17 years) ICD-10 codes:Z00.121 and Z00.129
CPT code 99385 – 18 years or older ICD codes: Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings

Established Patients

Periodic comprehensive preventive medicine reevaluation and management includes services and procedures similar to new patients.

CPT 99391 Infant (younger than 1 year)ICD-10 codes:Z00.110 Health supervision for newborn under 8 days old orZ00.111 Health supervision for newborn 8 to 28 days old orZ00.121 Routine child health exam with abnormal findings orZ00.129 Routine child health exam without abnormal findings
CPT 99392 Early childhood (age 1–4 years)ICD-10 codes: Z00.121 Z00.129
CPT 99393 Late childhood (age 5–11 years)
CPT 99394 Adolescent (age 12–17 years)
CPT 99395 18 years or olderICD-10 codes:Z00.00 General adult medical exam without abnormal findings andZ00.01 General adult medical exam with abnormal findings

Points to Note:

As preventive medicine service codes are not time-based, time spent during the visit is not relevant in the selection of the appropriate code.
The appropriate office or other outpatient service code (99201–99215) should be reported in addition to the preventive medicine service code if: an illness or abnormality is encountered, or a pre existing problem is addressed when performing the preventive medicine service, and if the illness, abnormality, or problem is significant enough to require additional work to perform the key components of a problem-oriented evaluation and management (E/M) service (history, physical examination, medical decision-making, or a combination of these).
Modifier 25 should be added on to the office or other outpatient service code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service
Do not report an insignificant or trivial illness, abnormality, or problem encountered in the process of performing the preventive medicine service that does not require additional work and performance of the key components of a problem-oriented E/M service.
Report the following separately from the preventive medicine service code: immunizations and ancillary studies involving laboratory, radiology, or other procedures, or screening tests (e.g., vision, developmental, and hearing screening) identified with a specific CPT code.

Other Commonly Reported ICD-10 Codes for Preventive Services

Encounter and Examination Codes

Z02.0 Examination for admission to educational institution Z02.4 Examination for driving license Z02.5 Examination for participation in sport Z01.00 Examination of eyes and vision without abnormal findings Z01.01 … with abnormal findings Z01.110 Hearing examination following failed hearing screening Z01.10 Encounter for examination of ears without abnormal findings Z01.118 … with other abnormal findings Z23 Immunizations – This is the only code in ICD-10-CM for vaccines, and has to be linked to both the product and administration CPT codes Z29.3 – Encounter for prophylactic fluoride administration

Screening Codes

A screening code is not necessary if the screening is inherent to a routine examination

Z11.1 Respiratory tuberculosis Z11.3 Infections with a predominantly sexual mode of transmission (excludes HPV and HIV) Z12.4 Encounter for screening for malignant Z12.79 Malignant neoplasm of other genitourinary Z12.89 Malignant neoplasms of other sites examination Z13.29 Other suspected endocrine disorder Z13.1 Diabetes mellitus Z13.228 Other metabolic disorders (e.g., inborn) Z13.220 Lipid disorders Z13.21 Nutritional disorder Z13.228 Other metabolic disorder Z13.29 Other suspected endocrine disorder examination Z13.0 Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (e.g., anemia, sickle cell) Z13.89 Other disorders (e.g., depression) Z13.4- Developmental disorders in childhood (excludes routine screening (e.g., autism) Z13.88 Disorder due to exposure to contaminants (e.g., lead)

Use of ICD-10 Codes When Immunizations Are Not Administered

Immunizations may not be administered during routine preventive medicine services if parents refuse vaccines or defer them, a patient may be ill at the time and it is counteractive to administer, or the patient may already have had the disease or be immune.

However, non-administration has to be reported as part of the ICD-10 for tracking purposes and quality measures. The ICD-10 codes to report when a vaccine is not given due to a certain condition are:

Z28.01 Acute illness Z28.02 Chronic illness or condition Z28.03 Immunocompromised state Z28.04 Allergy to vaccine or component Z28.1 Religious reasons Z28.20 Unspecified reason Z28.21 Patient refusal Z28.81 Patient has disease being vaccinated against Z28.82 Caregiver refusal Z28.89 Other reason

There are several other codes relevant to pediatric preventive medicine services. Moreover, certain insurance companies may require that HCPCS codes be reported in place of or as a supplement to CPT codes. Medical billing and coding outsourcing is a viable option for error-free reporting of pediatric preventative encounters in accordance with regulatory rules and payer requirements and ensure optimal reimbursement.

Being an experienced medical billing and coding company in the U.S., OSI is dedicated to staying abreast of the latest industry guidelines. Our services provide comprehensive support for the success of your practice.

CPT CODE 99381, 99382 – 99385 – Preventive visit new patient

Sep 25, 2016 | Medical billing basics

CPT Code and description

99381 – Initial comprehensive preventive medicine evaluation 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, new patient; infant (age younger than 1 year)

99382 – Initial comprehensive preventive medicine evaluation 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, new patient; early childhood (age 1 through 4 years)

99383 – Initial comprehensive preventive medicine evaluation 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, new patient; late childhood (age 5 through 11 years) – Average fee amount $110 – $130

99384 – Initial comprehensive preventive medicine evaluation 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, new patient; adolescent (age 12 through 17 years) Average fee amount $120 – $140

99385 – Initial comprehensive preventive medicine evaluation 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, new patient; 18-39 years – Average fee amount – $120 – $ 150

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397 , Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse Preventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

When a Preventive Medicine service and Other E/M services are provided during the same visit, only the Preventive Medicine service will be reimbursed.

Screening services include cervical cancer screening; pelvic and breast examination; prostate cancer screening/digital rectal examination; and obtaining, preparing and conveyance of a Papanicolaou smear to the laboratory. These Screening procedures are included in (and are not separately reimbursed from) the Preventive Medicine service rendered on the same day.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes.

Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes.

Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes.

Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

For a list of specific codes that are included in (and not separately reimbursed from) Preventive Medicine Services see the Applicable Codes section below.

For the purposes of this policy, Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional is defined as a physician, hospital, ambulatory surgical center, and/or other health care professional of the same group and Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional reporting the same Federal Tax Identification number.

PREVENTIVE MEDICINE SERVICES, NEW PATIENT

Initial comprehensive preventive medicine evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for a new patient.

Code Description

99381 Infant (age under 1 year) 99382 Early childhood (ages 1 through 4 years) 99383 Late childhood (ages 5 through 11 years) 99384 Adolescent (ages 12 through 17 years) 99385 18–39 years 99386 40–64 years 99387 65 years and over

PREVENTIVE MEDICINE SERVICES, ESTABLISHED PATIENT

Periodic comprehensive preventive medicine re-evaluation and management of an individual, including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations, laboratory/diagnostic procedures for an established patient.

Code Description 99391 Infant (age under 1 year) 99392 Early childhood (ages 1 through 4 years) 99393 Late childhood (ages 5 through 11 years) 99394 Adolescent (ages 12 through 17 years) 99395 18–39 years 99396 40–64 years 99397 65 years and over

New versus Established client: A new client is defined as one who has not received any professional services from a physician/qualified health care professional in your health department, within the last three years, for a billable visit that includes some level of evaluation and management (E/M) service coded as a preventive service using 99381-99387 or 99391-99397, or as an evaluation & management service using 99201-99205 and 99211-99215. If the client’s only visit to the Health Department is WIC or immunizations without one of the above service codes, it does not affect the designation of the client as a new client; the client can still be NEW. Remember that a client may be new to a program but established to the health department if they have received any professional services from a physician/qualified health care professional.

In this case, you would use the forms for a “new” patient for that program even though the client is billed as “established” to the health department. Due to National Correct Coding Initiative (NCCI) edits the practice of billing a 99211, and then later billing a new visit code, has been eliminated. Many LHDs have been billing a 99211 (usually an RN only visit) the first time they see a patient and then, up to 3 years later, bills a 99201 – 99205 or 99381-99387 (New Visit). Examples may include: billing the 99211 for pregnancy test counseling or head lice check by RN and then a new visit when the patient comes in for their first prenatal, Family Planning or Child Health visit. Now that the NCCI edits have been implemented, all of those “new” visits will deny because the LHD will have told the system (via billing a 99211) that the patient is “established.” Consult your PHNPDU Nursing Consultant if you have questions.

ADULT PREVENTIVE CARE PROCEDURE CODES

Code Description 76091 Mammogram (specialty center) 82270 Fecal Occult Blood Test (lab procedure code only) 82465 Total Serum Cholesterol (lab procedure code only) 84153 PSA (lab procedure code only) 86580 Tuberculosis (TB) Screening (PPD) 88150 Pap Smear (lab procedure code only) 90658 Flu Shot 90718 Td-Diphtheria–Tetanus Toxoid–0.5 ml 90732 Pneumovax

REIMBURSEMENT GUIDELINES Preventive Medicine Service and Problem Oriented E/M Service

A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended.

Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.

QUESTIONS AND ANSWERS 1 Q: Why does Oxford reduce reimbursement to 50% for an evaluation and management (E/M) service (99201-99205 or 99212-99215 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine service ?

A: Oxford recognizes that a visit may begin as a Preventive Medicine service, and in the process of the examination it may be determined that a disease related condition exists (evaluation and management). When this occurs, the level of decision-making during such a visit may be more complex than the decision-making during a Preventive Medicine visit. However, there are elements of the Preventive Medicine service (e.g., making the appointment, obtaining vital signs, maintaining and stocking the exam room, etc.) that are duplicated in the reimbursement for an E/M code; these duplicated practice expense services are 50% of the E/M cost.

2 Q: In what situation is CPT code 96110 reimbursable?

A: As defined, CPT code 96110 represents developmental screening with interpretation and report. In the introduction to the section in which this code appears, the CPT book states that “it is expected that the administration of these tests will generate material that will be formulated into a report.” Because a physician obtains developmental information as an intrinsic part of a preventive medicine service for an infant or child and because this information is sometimes obtained in the form of a questionnaire completed by the parents, it is expected that this code will be reported in addition to the preventive medicine visit only if the screening meets the code description. Physicians should report CPT code, for developmental screening or other similar screening or testing, separate and distinct from the Preventive medicine service only when the testing or screening results in an interpretation and report by the physician being entered into the medical record.

3 Q: Why is Q0091 not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers Q0091 (obtaining, preparing and conveying a cervical or vaginal smear to the laboratory) to be an integral part of a Preventive Health Care service. Therefore, this component of a Preventive visit is not separately reimbursable.

4 Q: Why is 99173 (screening test of visual acuity) not separately reimbursable when billed with a Preventive Medicine code?

A: Oxford considers vision screening using an eye chart to be integral to a Preventive Medicine examination in the same way that measurements of height, weight and blood pressure are integral to a Preventive Medicine examination. Therefore, vision screening using an eye chart is not reimbursed separately from a Preventive Medicine examination.

5 Q: Why is 99172 (visual function screening) not separately reimbursable when billed with a Preventive Medicine code?

A: The CPT Book clearly states that this service should not be reported in addition to an E/M code.

6 Q: How does Oxford reimburse for screening tests based on a questionnaire completed by the patient or a family member when done in conjunction with a Preventive Medicine service?

A: Counseling, anticipatory guidance and risk factor reduction interventions are integral to a Preventive Medicine visit. Historical information may be obtained either through direct questioning or through completion of a written questionnaire. The responses on a questionnaire often identify areas for more focused interventions or treatments. Since this screening is part of a Preventive Medicine service, it is not reimbursed separately. Occasionally, a screening instrument requires interpretation, scoring, and the development of a report separate from the Preventive Medicine encounter. In those situations, where a CPT code exists for that service, screening, interpretation and development of a report is reimbursed separately from a Preventive Medicine service. State Exceptions

Arizona Per Arizona State Regulations, effective 4/1/14 claims for EPSDT services must be submitted on a CMS (formerly HCFA) 1500 form for members up to age 21. Providers must bill for preventative EPSDT services using the preventative service, office or other outpatient services and preventive medicine CPT codes (99381 – 99385, 99391 – 99395) with an EP modifier.

EPSDT visits are paid at a global rate for the services specified and no additional reimbursement is allowed. Providers must use an EP modifier to designate all services related to the EPSDT well child check-ups, including routine vision and hearing screenings.

* A list of preventative, office or other outpatient services that are considered included in the global payment of the preventive medicine CPT code is attached to this policy

* Ocular photoscreening with interpretation and report, bilateral (CPT code 99174) is allowed for members under age 19. Arizona EPSDT Bundled Codes Lis t

A list of preventative, office or other outpatient services that are considered included in the global payment for the preventive medicine CPT codes (99381 – 99385, 99391 – 99395).

DC EPSDT Well-Child Visit Billing Reference Guide

When conducting a well-child visit (WCV), a primary care provider (PCP) must perform all components required in a visit and all age-appropriate screenings and/or assessments as required in the DC Medicaid HealthCheck Periodicity Schedule. Covered screening services are medical, developmental/mental health, vision, hearing and dental. The components of medical screening include:

* Comprehensive health and developmental history that assesses for both physical and mental health as well as for substance use disorders

* Comprehensive, unclothed physical examination

* Appropriate immunizations (as established by ACIP)

* Laboratory testing (including blood lead screening appropriate for age and risk factors)

* Health education and anticipatory guidance for both the child and the caregiver.i

To bill for a well-child visit:

* Use the age-based CPT code (99381-99385; 99391-99395). See Table 1.

o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code

* Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.

* If a screening or assessment is positive and requires follow-up or a referral, please use modifier TS with the applicable screening code that had a positive result.

DO NOT USE THE E&M OUTPATIENT VISIT CODES (99201-99205; 99213-99215) TO BILL FOR A WELLCHILD VISIT.

Table1: Age Based Preventive Visit CPT Codes Table 2: Screening/Assessment CPT Codes Patient’s Age CPT Code Dx Code

< 1 year 99381/91 new/established V20.31, 20.32, V20.2

1 – 4 years 99382/92 V20.2

5 – 11 years 99383/93 V20.2

12 – 17 years 99384/94 V20.2

18 – 21 years 99385/95 V70.0

HCY/EPSDT Billing Codes [1][2][3] AGE CPT Code: New Patient AGE CPT Code:

Established Patient Modifiers As Applicable ICD-10-CM Diagnosis Codes Preventive visit, Modifier EP: Used with procedure codes 99381-99385 and 99391-99395 when a Full or Partial screening is performed.

Modifier 52: Used with modifier EP when all components have not been met, but at least the first 5 or more components were completed according to the HCY/EPSDT requirements.

Modifier 59: Used when only components related to developmental and mental health are screened.

Modifier 25: Used on the significant, separately identifiable problem-oriented evaluation and management service when it is provided on (1) the same day as the preventive medicine service and/or (2) with administration of immunizations. Please note that modifier 25 is not to be used on preventive codes and needs to be billed using office or outpatient codes (99201-99215), and that these screenings bundle administration of immunizations.*Documentation must support the use of a modifier 25. See MO HealthNet Provider Manual. Modifier UC: Used when a referral is made for further care.

Z00.110 Newborn under 8 days old

Z00.111 Newborns 8 to 28 days old or

Z00.121 Routine child health exam with abnormal findings

Z00.129 Routine child health exam without abnormal findings Preventive visit, 1-4

99382 Preventive visit, 1-4

99392 Z00.121 Z00.129 Preventive visit, 5-11

99383 Preventive visit, 5-11

99393 Z00.121 Z00.129 Preventive visit, 12-17

99384 Preventive visit, 12-17

99394 Z00.121 Z00.129 Preventive visit, 18 or older

99385 Preventive visit, 18 or older

99395 Z00.00 General adult medical exam without abnormal findings Z00.01 General adult medical exam with abnormal findings

NCCI Edit with preventive visits

National Correct Coding Initiative (NCCI) Impacts on Immunization and Evaluation & Management (E&M) Codes Effective April 1, 2014, the Department will no longer reimburse NCCI procedure-to-procedure (PTP) edits when immunization administration procedure codes (CPT 90460-90474) are paired with preventative medicine E&M service procedure codes (CPT 99381-99397).

If a significant separately identifiable E&M service (e.g. new or established patient office or other outpatient services [99201-99215], office or other outpatient consultation [99241-99245], emergency department service [99281-99285], preventative medicine service [99381-99429] is performed), the appropriate E&M service code should be reported in addition to the vaccine and toxoid administration codes.

Each NCCI PTP edit has an assigned modifier indicator. A modifier indicator of “0” indicates that NCCI PTP-associated modifiers cannot be used to bypass the edit. A modifier indicator of “1” indicates that NCCI PTP-associated modifiers may be used to bypass an editunder appropriate circumstances. A modifier indicator of “9” indicates that the edit has been deleted, and the modifier indicator is not relevant. The Correct Coding Modifier Indicator can be found in the files containing Medicaid NCCI PTP edits on the CMS website.

A modifier should not be added to a HCPCS/CPT code solely to bypass an NCCI PTP edit, if the clinical circumstances do not justify its use. If the E&M service is significant and separately identifiable and performed on the same day, the E&M code should be billed with the vaccine and toxoid administration codes using PTP associated modifier ‘25’. Modifier ‘25’ is only valid when appended to the E&M codes. Do not append to the immunization administration procedure codes 90460-90474.

Therapeutic Injections Office visits (CPT codes 99201-99205; 99212-99215; 99381-99397) will not be separately reimbursed when submitted with therapeutic injections (CPT code 96372). Please append Modifier 25 to the disallowed E/M code if a significant separately identifiable E/M service was performed. Note: CPT code 96372 has been valued to include the work and practice expenses of CPT code 99211. A modifier will not override this edit.

Visual Acuity Testing CPT code 99173, visual acuity screening test, is separately reimbursable when submitted with preventive office visits (CPT codes 99381-99397). Vital Capacity Vital capacity (CPT code 94150) is considered incidental to the overall service provided, whether an office visit or a procedure, and will not be separately reimbursed.

Payment guidelines

Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402] are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses. Occasionally, an abnormality is encountered or a preexisting problem is addressed during the Preventive visit, and significant elements of related Evaluation and Management (E/M) services are provided during the same visit. When this occurs, Oxford will reimburse thePreventive Medicine service plus 50% the Problem-Oriented E/M service code when that code is appended with modifier 25. If the Problem-Oriented service is minor, or if the code is not submitted with modifier 25 appended, it will not be reimbursed.

Prolonged services are included in (and not separately reimbursed from) Preventive Medicine codes. Counseling services are included in (and not separately reimbursed from) Preventive Medicine codes. Medical Nutrition Therapy services are included in (and not separately reimbursed from) Preventive Medicine codes. Visual function screening and Visual Acuity screening are included in (and not separately reimbursed from) Preventive Medicine services.

Reporting Evaluation and Management Services With Immunizations

E/M services most often reported with the vaccine product and immunization administration include new and established patient preventive medicine visits (CPT codes 99381–99395), problem-oriented visits ( CPT 99201 –99215), and preventive medicine counseling services (99401–99404). Any of the aforementioned E/M codes can be reported as a single service or in combination when performed and documented on the same day of service by the same physician or physician of the same group and specialty.

The E/M service must be medically indicated, significant, and separately identifiable from the immunization administration.

• Payers may require modifier 25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to be appended to the E/M code to distinguish it from the administration of the vaccine.

• CPT code 99211 (established patient E/M, minimal level, not requiring physician presence) should not be reported when the patient encounter is for vaccination only because the Medicare Resource-BasedRelative Value Scale (RBRVS) relative values for the immunization administration codes incl de administrative and clinical services (ie, greeting the patient, routine vital signs, obtaining a vaccine history, presenting the VIS and responding to routine vaccine questions, preparation and administration of the vaccine, and documentation and observation of the patient following the administration of the vaccine). However, if the service is medically necessary, significant, and separately identifiable, it may be reported with modifier 25 appended to the E/M code (99211). Note that the medical record must clearly state the reason for the visit, brief history, physical examination, assessment and plan, and any other counseling or discussion items. The progress note must be signed with the physician’s countersignature. For more information and clinical vignettes on the appropriate use of code 99211 during immunization administration, visit www.aap.org/pubserv/codingforpeds for a copy of the AAP position paper on reporting 99211 with immunization administration. Payers who do not follow the Medicare RBRVS may allow payment of code 99211 with immunization administration. Know your payer guidelines, and if payment is allowed, make certain that the guidelines are in writing and maintained in your office. Be aware that a co-payment will be required when the “nurse” visit is reported.

• The same guidelines apply to physician visits (99201–99215). In other words, if a patient is seen for the administration of a vaccine only, it is not appropriate to report an E/M visit if it is not medically necessary, significant, and separately identifiable.

• If at the time of a preventive medicine visit a patient has a problem or abnormality that is addressed and requires significant additional work to perform the required key components, a problem-oriented E/M code (99201–99215) may be reported in addition to the preventive medicine services code. There should be separate documentation for the 2 services in the medical record. Typically the level of service is based on the level of history and medical decision-making that are performed and documented because the physical examination component is most often performed as part of the age-appropriate examination included in the preventive medicine service. Modifier 25 must be appended to the problemoriented E/M service to alert the payer that it was significant and separately identifiable. Each code is linked to the appropriate ICD-9-CM code.

CPT codes 99401–99404 (preventive medicine counseling, individual) are used for the purpose of promoting health and preventing illness or injury. They are not reported when counseling is related to a condition, disease, or treatment. These are time-based codes that require medical record documentation of the total time spent in counseling and a summary of the issues discussed. Codes 99401–99404 may be reported separately from other E/M services (eg, office visits, preventive medicine visits) when performed on the same day. Modifier 25 must be appended to codes 99401– 99404 to signify to the payer that the preventive medicine counseling was significant and separately identifiable from the preventive medicine or problem-oriented E/M visit.

• Remember that reviewing or discussing the risks and benefits of vaccines and addressing all other patient and parent concerns and questions related to vaccines and immunization administration are included in the immunization administration codes. However, if vaccine counseling is performed and the parent or patient refuses vaccines, the time spent in counseling may be separately reported. Also, if after additional time is spent in vaccine counseling, the parent or patient then decides to accept the immunizations and the time and effort exceeds that normally spent by the physician, it is still appropriate to report these codes in addition to the E/M visit and immunization administration. Make certain that the medical record supports the excess time and effort of counseling.

Billing for Medically Necessary Visit on Same Occasion as Preventive Medicine Service

When a physician furnishes a Medicare beneficiary a covered visit at the same place and on the same occasion as a noncovered preventive medicine service (CPT codes 99381- 99397), consider the covered visit to be provided in lieu of a part of the preventive

medicine service of equal value to the visit. A preventive medicine service (CPT codes 99381-99397) is a noncovered service. The physician may charge the beneficiary, as a charge for the noncovered remainder of the service, the amount by which the physician’s current established charge for the preventive medicine service exceeds his/her current established charge for the covered visit. Pay for the covered visit based on the lesser of the fee schedule amount or the physician’s actual charge for the visit. The physician is not required to give the beneficiary written advance notice of noncoverage of the part of the visit that constitutes a routine preventive visit. However, the physician is responsible for notifying the patient in advance of his/her liability for the charges for services that are not medically necessary to treat the illness or injury.

There could be covered and noncovered procedures performed during this encounter (e.g., screening x-ray, EKG, lab tests.). These are considered individually. Those procedures which are for screening for asymptomatic conditions are considered noncovered and, therefore, no payment is made. Those procedures ordered to diagnose or monitor a symptom, medical condition, or treatment are evaluated for medical necessity and, if covered, are paid.

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Newborn Care Services 101

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Newborns typically fall into one of four clinical situations

Normal Newborn
Sick Newborn
Intensive Care Needs
Critical Care Needs

Normal Newborn Care Services

According to the American Academy of Pediatrics , a normal newborn is defined as:

Transitions to life in the usual manner
May require delivery room intervention, but is normal after transition
May require testing or follow-up (bilirubin, CBC, or culture, etc.)
Significant intervention not required
May be observed, but without signs/symptoms currently
Preterm with no special care required
May be present with sick contacts (mother, twin, sibling)
May have some condition described by ICD-10, but is still normal

Newborn Care Services are described in CPT codes 99460 – 99463.

“Sick” Newborn Care Services

CPT states that initiation of hospital inpatient or observation care for the ill neonate NOT requiring intensive care (defined as requiring intensive observation, frequent interventions, and other intensive care services), see codes 99221-99223.

Newborn Intensive Care Services

Intensive Care Services code set (99477 – 99480) is appropriate for use when a child is NOT critically ill, but still requires intensive observation, frequent interventions, and other intensive care services. Code selection is based on the newborn’s condition (needing intensive services), age, and/or weight.

Newborn Critical Care Services

CPT describes “per day” neonatal critical care codes by age:

99468 – Initial Inpatient Neonatal Critical Care, per day , for the evaluation and management of a critically ill neonate, 28 days or younger
99469 – Subsequent Inpatient Neonatal Critical Care, per day , for the evaluation and management of a critically ill neonate, 28 days or younger
99471 – Initial Inpatient Neonatal Critical Care, per day , for the evaluation and management of a critically ill neonate, 29 days – 24 months of age
99472 – Subsequent Inpatient Neonatal Critical Care, per day , for the evaluation and management of a critically ill neonate, 29 days – 24 months of age

Critical Care Services performed during transport may be reported using 99466 – 99486.

Pediatric Critical Care Services (99475, 99476 and 99291, 99292) will be described in a separate article apart from Newborn Care Services.

Understand that a newborn can be on different ends of the spectrum of a diagnosis. Your documentation paints the picture that substantiates the need for newborn sick, intensive, or critical care services. Let’s take a look at the possible scenarios for hypoglycemia.

Hypoglycemia

Sick Care – If glucose levels are stable and do not require frequent monitoring or adjustment hospital care codes (99221-99233) may be more suitable.

Intensive Care – If infants require continuous intravenous glucose supplementation with frequent monitoring and multiple adjustments of IV glucose rates or if a central venous line (e.g., umbilical venous line) was placed to accommodate high concentrations of glucose, intensive care codes (99477-99480) may be used.

Critical Care – Persistent hypoglycemia (often due to hyperinsulinism) in the setting of elevated glucose infusion rates requiring the addition of diazoxide or glucagon may justify critical care coding (99468-99472).

We have prepared a presentation for the Pediatric Step-Down Team ( ppt ) ( handouts ). Additionally, we put together the Newborn Care Services tip sheet to compliment this training.

Other Resources

AAP: Daily Code (Global or Per Diem) Critical Care Guidance

(NEW!) February 2024 – Concurrent Care CHI Presentation ( ppt ) ( tip sheet ) ( Recording )

If you would like more information, please reach out to [email protected] , [email protected] , or [email protected] .

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KATHERINE TURNER, MD

Am Fam Physician. 2018;98(6):347-353

Related letter: Well-Child Visits Provide Physicians Opportunity to Deliver Interconception Care to Mothers

Author disclosure: No relevant financial affiliations.

The well-child visit allows for comprehensive assessment of a child and the opportunity for further evaluation if abnormalities are detected. A complete history during the well-child visit includes information about birth history; prior screenings; diet; sleep; dental care; and medical, surgical, family, and social histories. A head-to-toe examination should be performed, including a review of growth. Immunizations should be reviewed and updated as appropriate. Screening for postpartum depression in mothers of infants up to six months of age is recommended. Based on expert opinion, the American Academy of Pediatrics recommends developmental surveillance at each visit, with formal developmental screening at nine, 18, and 30 months and autism-specific screening at 18 and 24 months; the U.S. Preventive Services Task Force found insufficient evidence to make a recommendation. Well-child visits provide the opportunity to answer parents' or caregivers' questions and to provide age-appropriate guidance. Car seats should remain rear facing until two years of age or until the height or weight limit for the seat is reached. Fluoride use, limiting or avoiding juice, and weaning to a cup by 12 months of age may improve dental health. A one-time vision screening between three and five years of age is recommended by the U.S. Preventive Services Task Force to detect amblyopia. The American Academy of Pediatrics guideline based on expert opinion recommends that screen time be avoided, with the exception of video chatting, in children younger than 18 months and limited to one hour per day for children two to five years of age. Cessation of breastfeeding before six months and transition to solid foods before six months are associated with childhood obesity. Juice and sugar-sweetened beverages should be avoided before one year of age and provided only in limited quantities for children older than one year.

Well-child visits for infants and young children (up to five years) provide opportunities for physicians to screen for medical problems (including psychosocial concerns), to provide anticipatory guidance, and to promote good health. The visits also allow the family physician to establish a relationship with the parents or caregivers. This article reviews the U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) guidelines for screenings and recommendations for infants and young children. Family physicians should prioritize interventions with the strongest evidence for patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening.

Clinical Examination

The history should include a brief review of birth history; prematurity can be associated with complex medical conditions. 1 Evaluate breastfed infants for any feeding problems, 2 and assess formula-fed infants for type and quantity of iron-fortified formula being given. 3 For children eating solid foods, feeding history should include everything the child eats and drinks. Sleep, urination, defecation, nutrition, dental care, and child safety should be reviewed. Medical, surgical, family, and social histories should be reviewed and updated. For newborns, review the results of all newborn screening tests ( Table 1 4 – 7 ) and schedule follow-up visits as necessary. 2

PHYSICAL EXAMINATION

A comprehensive head-to-toe examination should be completed at each well-child visit. Interval growth should be reviewed by using appropriate age, sex, and gestational age growth charts for height, weight, head circumference, and body mass index if 24 months or older. The Centers for Disease Control and Prevention (CDC)-recommended growth charts can be found at https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts . Percentiles and observations of changes along the chart's curve should be assessed at every visit. Include assessment of parent/caregiver-child interactions and potential signs of abuse such as bruises on uncommonly injured areas, burns, human bite marks, bruises on nonmobile infants, or multiple injuries at different healing stages. 8

The USPSTF and AAP screening recommendations are outlined in Table 2 . 3 , 9 – 27 A summary of AAP recommendations can be found at https://www.aap.org/en-us/Documents/periodicity_schedule.pdf . The American Academy of Family Physicians (AAFP) generally adheres to USPSTF recommendations. 28

MATERNAL DEPRESSION

Prevalence of postpartum depression is around 12%, 22 and its presence can impair infant development. The USPSTF and AAP recommend using the Edinburgh Postnatal Depression Scale (available at https://www.aafp.org/afp/2010/1015/p926.html#afp20101015p926-f1 ) or the Patient Health Questionnaire-2 (available at https://www.aafp.org/afp/2012/0115/p139.html#afp20120115p139-t3 ) to screen for maternal depression. The USPSTF does not specify a screening schedule; however, based on expert opinion, the AAP recommends screening mothers at the one-, two-, four-, and six-month well-child visits, with further evaluation for positive results. 23 There are no recommendations to screen other caregivers if the mother is not present at the well-child visit.

PSYCHOSOCIAL

With nearly one-half of children in the United States living at or near the poverty level, assessing home safety, food security, and access to safe drinking water can improve awareness of psychosocial problems, with referrals to appropriate agencies for those with positive results. 29 The prevalence of mental health disorders (i.e., primarily anxiety, depression, behavioral disorders, attention-deficit/hyperactivity disorder) in preschool-aged children is around 6%. 30 Risk factors for these disorders include having a lower socioeconomic status, being a member of an ethnic minority, and having a non–English-speaking parent or primary caregiver. 25 The USPSTF found insufficient evidence regarding screening for depression in children up to 11 years of age. 24 Based on expert opinion, the AAP recommends that physicians consider screening, although screening in young children has not been validated or standardized. 25

DEVELOPMENT AND SURVEILLANCE

Based on expert opinion, the AAP recommends early identification of developmental delays 14 and autism 10 ; however, the USPSTF found insufficient evidence to recommend formal developmental screening 13 or autism-specific screening 9 if the parents/caregivers or physician have no concerns. If physicians choose to screen, developmental surveillance of language, communication, gross and fine movements, social/emotional development, and cognitive/problem-solving skills should occur at each visit by eliciting parental or caregiver concerns, obtaining interval developmental history, and observing the child. Any area of concern should be evaluated with a formal developmental screening tool, such as Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Parents' Evaluation of Developmental Status-Developmental Milestones, or Survey of Well-Being of Young Children. These tools can be found at https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/Screening/Pages/Screening-Tools.aspx . If results are abnormal, consider intervention or referral to early intervention services. The AAP recommends completing the previously mentioned formal screening tools at nine-, 18-, and 30-month well-child visits. 14

The AAP also recommends autism-specific screening at 18 and 24 months. 10 The USPSTF recommends using the two-step Modified Checklist for Autism in Toddlers (M-CHAT) screening tool (available at https://m-chat.org/ ) if a physician chooses to screen a patient for autism. 10 The M-CHAT can be incorporated into the electronic medical record, with the possibility of the parent or caregiver completing the questionnaire through the patient portal before the office visit.

IRON DEFICIENCY

Multiple reports have associated iron deficiency with impaired neurodevelopment. Therefore, it is essential to ensure adequate iron intake. Based on expert opinion, the AAP recommends supplements for preterm infants beginning at one month of age and exclusively breastfed term infants at six months of age. 3 The USPSTF found insufficient evidence to recommend screening for iron deficiency in infants. 19 Based on expert opinion, the AAP recommends measuring a child's hemoglobin level at 12 months of age. 3

Lead poisoning and elevated lead blood levels are prevalent in young children. The AAP and CDC recommend a targeted screening approach. The AAP recommends screening for serum lead levels between six months and six years in high-risk children; high-risk children are identified by location-specific risk recommendations, enrollment in Medicaid, being foreign born, or personal screening. 21 The USPSTF does not recommend screening for lead poisoning in children at average risk who are asymptomatic. 20

The USPSTF recommends at least one vision screening to detect amblyopia between three and five years of age. Testing options include visual acuity, ocular alignment test, stereoacuity test, photoscreening, and autorefractors. The USPSTF found insufficient evidence to recommend screening before three years of age. 26 The AAP, American Academy of Ophthalmology, and the American Academy of Pediatric Ophthalmology and Strabismus recommend the use of an instrument-based screening (photoscreening or autorefractors) between 12 months and three years of age and annual visual acuity screening beginning at four years of age. 31

IMMUNIZATIONS

The AAFP recommends that all children be immunized. 32 Recommended vaccination schedules, endorsed by the AAP, the AAFP, and the Advisory Committee on Immunization Practices, are found at https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season. Additional vaccinations may be necessary based on medical history. 33 Immunization history should be reviewed at each wellness visit.

Anticipatory Guidance

Injuries remain the leading cause of death among children, 34 and the AAP has made several recommendations to decrease the risk of injuries. 35 – 42 Appropriate use of child restraints minimizes morbidity and mortality associated with motor vehicle collisions. Infants need a rear-facing car safety seat until two years of age or until they reach the height or weight limit for the specific car seat. Children should then switch to a forward-facing car seat for as long as the seat allows, usually 65 to 80 lb (30 to 36 kg). 35 Children should never be unsupervised around cars, driveways, and streets. Young children should wear bicycle helmets while riding tricycles or bicycles. 37

Having functioning smoke detectors and an escape plan decreases the risk of fire- and smoke-related deaths. 36 Water heaters should be set to a maximum of 120°F (49°C) to prevent scald burns. 37 Infants and young children should be watched closely around any body of water, including water in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-closing, self-latching gate. 38

Infants should not be left alone on any high surface, and stairs should be secured by gates. 43 Infant walkers should be discouraged because they provide no benefit and they increase falls down stairs, even if stair gates are installed. 39 Window locks, screens, or limited-opening windows decrease injury and death from falling. 40 Parents or caregivers should also anchor furniture to a wall to prevent heavy pieces from toppling over. Firearms should be kept unloaded and locked. 41

Young children should be closely supervised at all times. Small objects are a choking hazard, especially for children younger than three years. Latex balloons, round objects, and food can cause life-threatening airway obstruction. 42 Long strings and cords can strangle children. 37

DENTAL CARE

Infants should never have a bottle in bed, and babies should be weaned to a cup by 12 months of age. 44 Juices should be avoided in infants younger than 12 months. 45 Fluoride use inhibits tooth demineralization and bacterial enzymes and also enhances remineralization. 11 The AAP and USPSTF recommend fluoride supplementation and the application of fluoride varnish for teeth if the water supply is insufficient. 11 , 12 Begin brushing teeth at tooth eruption with parents or caregivers supervising brushing until mastery. Children should visit a dentist regularly, and an assessment of dental health should occur at well-child visits. 44

SCREEN TIME

Hands-on exploration of their environment is essential to development in children younger than two years. Video chatting is acceptable for children younger than 18 months; otherwise digital media should be avoided. Parents and caregivers may use educational programs and applications with children 18 to 24 months of age. If screen time is used for children two to five years of age, the AAP recommends a maximum of one hour per day that occurs at least one hour before bedtime. Longer usage can cause sleep problems and increases the risk of obesity and social-emotional delays. 46

To decrease the risk of sudden infant death syndrome (SIDS), the AAP recommends that infants sleep on their backs on a firm mattress for the first year of life with no blankets or other soft objects in the crib. 45 Breastfeeding, pacifier use, and room sharing without bed sharing protect against SIDS; infant exposure to tobacco, alcohol, drugs, and sleeping in bed with parents or caregivers increases the risk of SIDS. 47

DIET AND ACTIVITY

The USPSTF, AAFP, and AAP all recommend breastfeeding until at least six months of age and ideally for the first 12 months. 48 Vitamin D 400 IU supplementation for the first year of life in exclusively breastfed infants is recommended to prevent vitamin D deficiency and rickets. 49 Based on expert opinion, the AAP recommends the introduction of certain foods at specific ages. Early transition to solid foods before six months is associated with higher consumption of fatty and sugary foods 50 and an increased risk of atopic disease. 51 Delayed transition to cow's milk until 12 months of age decreases the incidence of iron deficiency. 52 Introduction of highly allergenic foods, such as peanut-based foods and eggs, before one year decreases the likelihood that a child will develop food allergies. 53

With approximately 17% of children being obese, many strategies for obesity prevention have been proposed. 54 The USPSTF does not have a recommendation for screening or interventions to prevent obesity in children younger than six years. 54 The AAP has made several recommendations based on expert opinion to prevent obesity. Cessation of breastfeeding before six months and introduction of solid foods before six months are associated with childhood obesity and are not recommended. 55 Drinking juice should be avoided before one year of age, and, if given to older children, only 100% fruit juice should be provided in limited quantities: 4 ounces per day from one to three years of age and 4 to 6 ounces per day from four to six years of age. Intake of other sugar-sweetened beverages should be discouraged to help prevent obesity. 45 The AAFP and AAP recommend that children participate in at least 60 minutes of active free play per day. 55 , 56

Data Sources: Literature search was performed using the USPSTF published recommendations ( https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations ) and the AAP Periodicity table ( https://www.aap.org/en-us/Documents/periodicity_schedule.pdf ). PubMed searches were completed using the key terms pediatric, obesity prevention, and allergy prevention with search limits of infant less than 23 months or pediatric less than 18 years. The searches included systematic reviews, randomized controlled trials, clinical trials, and position statements. Essential Evidence Plus was also reviewed. Search dates: May through October 2017.

Gauer RL, Burket J, Horowitz E. Common questions about outpatient care of premature infants. Am Fam Physician. 2014;90(4):244-251.

American Academy of Pediatrics; Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010;125(2):405-409.

Baker RD, Greer FR Committee on Nutrition, American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040-1050.

Mahle WT, Martin GR, Beekman RH, Morrow WR Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012;129(1):190-192.

American Academy of Pediatrics Newborn Screening Authoring Committee. Newborn screening expands: recommendations for pediatricians and medical homes—implications for the system. Pediatrics. 2008;121(1):192-217.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898-921.

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or = 35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193-1198.

Christian CW Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse [published correction appears in Pediatrics . 2015;136(3):583]. Pediatrics. 2015;135(5):e1337-e1354.

Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for autism spectrum disorder in young children: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691-696.

Johnson CP, Myers SM American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.

Moyer VA. Prevention of dental caries in children from birth through age 5 years: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111.

Clark MB, Slayton RL American Academy of Pediatrics Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.

Siu AL. Screening for speech and language delay and disorders in children aged 5 years and younger: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2015;136(2):e474-e481.

Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics . 2006;118(4):1808–1809]. Pediatrics. 2006;118(1):405-420.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for lipid disorders in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-633.

National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. October 2012. https://www.nhlbi.nih.gov/sites/default/files/media/docs/peds_guidelines_full.pdf . Accessed May 9, 2018.

Moyer VA. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613-619.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics . 2017;140(6):e20173035]. Pediatrics. 2017;140(3):e20171904.

Siu AL. Screening for iron deficiency anemia in young children: USPSTF recommendation statement. Pediatrics. 2015;136(4):746-752.

U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518.

Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials . Atlanta, Ga.: U.S. Public Health Service; Centers for Disease Control and Prevention; National Center for Environmental Health; 1997.

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and post-partum women: evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(4):388-406.

Earls MF Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039.

Siu AL. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.

Weitzman C, Wegner L American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics; Committee on Psychosocial Aspects of Child and Family Health; Council on Early Childhood; Society for Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems [published correction appears in Pediatrics . 2015;135(5):946]. Pediatrics. 2015;135(2):384-395.

Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children aged 6 months to 5 years: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;318(9):836-844.

Donahue SP, Nixon CN Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Academy of Pediatrics; American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

Lin KW. What to do at well-child visits: the AAFP's perspective. Am Fam Physician. 2015;91(6):362-364.

American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.

Lavigne JV, Lebailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol. 2009;38(3):315-328.

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment of infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

American Academy of Family Physicians. Clinical preventive service recommendation. Immunizations. http://www.aafp.org/patient-care/clinical-recommendations/all/immunizations.html . Accessed October 5, 2017.

Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Accessed May 9, 2018.

National Center for Injury Prevention and Control. 10 leading causes of death by age group, United States—2015. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif . Accessed April 24, 2017.

Durbin DR American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788-793.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics. 2000;105(6):1355-1357.

Gardner HG American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(1):202-206.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(2):437-439.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790-792.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001;107(5):1188-1191.

Dowd MD, Sege RD Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416-e1423.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010;125(3):601-607.

Kendrick D, Young B, Mason-Jones AJ, et al. Home safety education and provision of safety equipment for injury prevention (review). Evid Based Child Health. 2013;8(3):761-939.

American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224-1229.

Heyman MB, Abrams SA American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967.

Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591.

Moon RY Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162940.

American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

Wagner CL, Greer FR American Academy of Pediatrics Section on Breastfeeding; Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics . 2009;123(1):197]. Pediatrics. 2008;122(5):1142-1152.

Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics. 2011;127(3):e544-e551.

Greer FR, Sicherer SH, Burks AW American Academy of Pediatrics Committee on Nutrition; Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.

American Academy of Pediatrics Committee on Nutrition. The use of whole cow's milk in infancy. Pediatrics. 1992;89(6 pt 1):1105-1109.

Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract. 2013;1(1):29-36.

Grossman DC, Bibbins-Domingo K, Curry SJ, et al. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.

Daniels SR, Hassink SG Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.

American Academy of Family Physicians. Physical activity in children. https://www.aafp.org/about/policies/all/physical-activity.html . Accessed January 1, 2018.

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Perinatal Care

Coding definitions of the perinatal and neonatal periods, expectant parent visits, normal newborn care, icd-10-cm codes for newborn services, hospital care of the ill newborn, choosing normal newborn care or hospital care, attendance at delivery, diagnosis codes for perinatal conditions, daily hospital care of the ill newborn, initial inpatient hospital or observation care, subsequent hospital care, discharge management, consultations, prolonged e/m service on the date of a hospital encounter, prolonged e/m service on a date before or after a direct service, coding for transitions to different levels of neonatal care, other newborn hospital care, circumcision, car safety seat testing, aap coding assistance and education, 16: hospital care of the newborn.

Published: October 2023
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"Hospital Care of the Newborn", Coding for Pediatrics 2024 : A Manual for Pediatric Documentation and Payment , Committee on Coding and Nomenclature, American Academy of Pediatrics, Linda D. Parsi, MD, MBA, CPEDC, FAAP

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Chapter Highlights

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Neonatal period diagnoses and procedure code selection

Codes for normal newborn and hospital inpatient care

Codes for services throughout the course of the birth admission

Coding for transitions to different levels of service

This chapter focuses on coding for care of the typical newborn and newborns with conditions not requiring intensive monitoring or critical care.

The American Academy of Pediatrics (AAP) Section on Neonatal-Perinatal Medicine, in conjunction with state chapters and councils of the AAP, has developed strategies that have been successful in addressing payment concerns for neonatal care. Contact your state chapter, its pediatric council, your section district AAP Executive Committee representative, a neonatal trainer, or the AAP Committee on Coding and Nomenclature for assistance in addressing any payment inequities for neonatal services in your state.

You can also complete the AAP Hassle Factor Form ( https://form.jotform.com/Subspecialty/aapcodinghotline ).

For coding purposes, the perinatal period commences before birth and continues through the 28th day following birth. According to this definition, the neonatal period begins at birth and continues through the completed 28th day after birth , ending on the 29th calendar day after birth. The day of birth is considered day 0 (zero). Therefore, the day after birth is considered day 1. This definition is important for selection of the correct diagnosis codes for conditions that originate in the perinatal period. (It is also important for selection of codes for neonatal critical care and initial intensive care.)

When expectant parents request a visit to meet the pediatrician and learn about the practice, these “meet and greet” visits are not typically considered a medically necessary service. But many pediatric practices establish policies for managing this type of visit, often at times when the practice is least busy, as a non-billable service used for marketing the practice.

Refer to the Consultations section later in this chapter for an example of a clinically indicated consultation provided to expectant parents at the request of another physician or other appropriate source (eg, to address risk reduction and plan newborn care in the presence of identified or suspected abnormalities). A service requested by an expectant parent is not a consultation.

Current Procedural Terminology ( CPT ® ) codes for care of a normal newborn typically follow a pathway of daily care from initial care to subsequent care and/or discharge day management depending on the length of the newborn’s hospital stay. Notable exceptions are newborns admitted and discharged on the same date ( 99463 ) and newborns receiving initial care in settings other than a hospital or birthing center ( 99461 ).

A normal newborn may be defined as a newborn who

Experiences a normal transition period after birth

May require delivery room intervention, as discussed in the Attendance at Delivery section later in this chapter, but is normal after transition

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

Does not require significant intervention(s)

May be observed for illness related to maternal pregnancy complication but is not sick

May be born with a nonthreatening anomaly (eg, polydactyly)

May be late preterm but requires no special care

May be in house with sick mother/twin

Normal newborn codes can be reported for care provided to neonates who are acting normally but recovering from fetal stress or a low Apgar score or who are being observed for a potential problem but are asymptomatic.

Codes 99460 , 99462 , 99463 , 99238 , and 99239 are used to report evaluation and management (E/M) services provided to the healthy newborn in a health care facility such as a hospital, including birthing room deliveries, or birthing center. They are reported when the neonate is cared for in the mother’s room (rooming-in), a labor and delivery room, a post-partum floor, or a traditional newborn nursery and when a normal neonate is cared for after the mother is discharged (eg, awaiting foster care).

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

Codes 99460–99463 are not reported for telemedicine services unless specified in payer policy. These codes are not included in the CPT listing of codes reported with modifier 95 (synchronous telemedicine service) or modifier 93 (telemedicine service via real-time interactive audio-only telecommunications system).

Guidelines for reporting include

● The neonate is considered admitted at the time of leaving the delivery room.

● Code 99463 (history and examination of the normal newborn, including discharge) should be reported when an initial history and physical examination and the discharge management are performed on the same calendar date for a normal newborn.

✖ Do not report 99463 when discharge occurs on the next calendar date even if less than 24 hours has passed since the initial newborn care.

● Code 99460 (history and examination of the normal newborn, initial service) is reported only once on the first day that the physician provides a face-to-face service in the facility. This date may not necessarily correlate with the date the patient is born or the hospital admission date.

● Code 99462 (subsequent hospital care, normal newborn) is reported once per calendar date on the date(s) subsequent to the initial normal newborn care service but not on the date of a discharge management service.

● Discharge management services performed on a day subsequent to initial newborn care are reported with 99238 (hospital discharge day management; 30 minutes or less) or 99239 (hospital discharge day management; more than 30 minutes). Time must be documented when reporting 99239 .

— Include time spent in final examination of the patient, discussion of the hospital stay, instructions to parents/ caregivers for continuing care, and preparation of discharge records, prescriptions, and referral forms.

Discharge day management codes 99238 and 99239 are valued higher than the subsequent newborn hospital care code ( 99462 ) to include the physician’s time and work, such as reviewing and documenting the hospital stay and counseling parents about continuing care of their neonate.

● Any additional procedures (eg, 54150 , circumcision using clamp or other device with dorsal penile or ring block) should be reported in addition to normal newborn care codes. Modifier 25 (significant, separately identifiable E/M service) should be appended to the E/M code when a procedure is performed on the same day of service.

✖ When reporting an E/M service based on time (eg, discharge day management), do not include the time spent providing a separately reported service (eg, circumcision) in the time of the E/M service (eg, obtaining consent, providing post-procedural care instruction).

International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ) codes from category Z38 are used to report live-born neonates according to type of birth and are the first-listed codes for care by the attending or admitting physician during the entire birth admission. Other physicians providing care during the birth admission do not report Z38 codes but, instead, report codes for the condition(s) they managed at each encounter. Category Z38 codes for single and twin live-born neonates are shown in Box 16-1 .

Refer to the ICD-10-CM manual for Z38 codes for other multiple-birth neonates.

Report ICD-10-CM code Z76.2 (encounter for health supervision and care of other healthy infant and child) when a healthy newborn continues to receive daily visits pending discharge of the mother or foster care placement or for other reasons. Code Z76.2 is useful for indicating the reason for an extended stay of a healthy newborn. Report Z76.2 as secondary to the appropriate Z38 code for services by the attending physician during the birth admission.

➤ The physician receives a late-night call about the vaginal delivery of a healthy full-term boy. A nurse relates that the newborn has been admitted and seems fine. The physician’s standing admission orders are followed, and the physician examines the newborn the following morning. The physician reviews the record, examines the neonate, and speaks with the mother. The physician performs circumcision of the newborn ( 54150 ) later that day as requested by the parents. The newborn and mother remain in the hospital until the next day, when both are then discharged home. Discharge management takes 25 minutes. ICD-10-CM . CPT . Diagnosis code for all days Z38.00 (single liveborn, delivered vaginally) Day 1: No charge (no face-to-face services provided) Day 2: 99460 25 (initial normal newborn care) 54150 (circumcision, using clamp or other device with regional dorsal penile or ring block) Day 3: 99238 (hospital discharge management; 30 minutes or less) View Large Teaching Point: Report newborn hospital care only when a face-to-face service is provided. The date of the attending physician’s first evaluation of the newborn is the date of initial newborn care. When a procedure (eg, circumcision) is provided on the same date as a newborn care service, modifier 25 is appended to the code for newborn care to signify that the E/M service was significant and separately identifiable from the preservice and postservice work of the procedure in the documentation.

➤ A baby is born vaginally in the hospital on March 3 at 4:00 pm. The physician first sees the baby on March 4 at 7:00 am and, later the same date, determines that the newborn is ready for discharge. A history and examination of the newborn, discussion of the hospital stay with the parents, instructions for continuing care, family counseling, and preparation of the final discharge records are performed. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) 99463 (initial normal newborn care and discharge on the same date) View Large Teaching Point: The physician’s combined services are reported with 99463 .

➤ A subsequent hospital visit is performed in the well-baby nursery on a vaginally delivered 2-day-old who is being observed for jaundice caused by hyperbilirubinemia; however, no interventions are noted, and the baby is doing well. Diagnosis is neonatal hyperbilirubinemia . ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P59.9 (neonatal jaundice, unspecified) 99462 (subsequent normal newborn care) View Large Teaching Point: The service is normal newborn care even though the newborn is being observed for risk of jaundice. The first-listed diagnosis code is Z38.00 . For neonatal hyperbilirubinemia, report ICD-10-CM code P59.9 (neonatal jaundice, unspecified).

➤ During a subsequent newborn care visit, the physician notes that the newborn failed the routine hearing screening . The attending physician spends 15 minutes discussing the results with the parents and refers to an audiologist for testing to confirm or rule out hearing abnormality. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) R94.120 (abnormal auditory function study) 99462 (subsequent normal newborn care) View Large Teaching Point: The time spent providing the subsequent newborn care does not affect code selection, as normal newborn care services are reported per day, not per hour. Only Z38.00 is reported when the result of an auditory screening is normal. An audiologist performing confirmatory testing would report Z01.110 (encounter for hearing examination following failed hearing screening) and codes for any identified conditions.

The choice between coding for normal newborn care and coding for hospital care is based on the physician’s judgment and the type of symptoms demonstrated. Services to newborns that require an increased level of physician care, nursing observation, or physiologic monitoring (but not intensive care as described by 99477–99480 ) are typically reported with hospital inpatient or observation care codes (initial, 99221–99223 ; subsequent, 99231–99233 ).

A sick-newborn visit includes a manifesting problem that supports the need for diagnostic investigation or therapy. Therapeutic intervention is typically necessary for the sick newborn.

The nature of the manifesting problem and extent of work required to diagnose and manage the problem should be considered when determining the appropriate procedure code.

Attendance at delivery ( 99464 ) is not reported when hospital-mandated attendance is the only basis for providing the service. When physician on-call services are mandated by the hospital (eg, attending all repeated cesarean deliveries) and not physician requested, report 99026 (hospital-mandated on-call service; in hospital, each hour) or 99027 (hospital-mandated on-call service; out of hospital, each hour).

Attendance at delivery ( 99464 )

Service is reported only when requested by the delivering physician and indicated for a newborn who may require immediate intervention (ie, stabilization, resuscitation, or evaluation for potential problems).

Medical record documentation must include the request for attendance at the delivery and substantiate the medical necessity of the services performed. If there is no documentation by the delivering physician for attendance at delivery, the verbal request and the reason for the request should be documented in the attendance note.

Includes initial drying, stimulation, suctioning, blow-by oxygen, or continuous positive airway pressure (CPAP) or high-flow air/oxygen without positive pressure ventilation; a cursory visual inspection of the neonate; assignment of Apgar scores; and discussion of care for the newborn with the delivering physician and parents. A quick look into the delivery room or examination after stabilization is not sufficient to report 99464 . Refer to the “Coding Conundrum: What Service Can Be Reported When a Physician Arrives After Delivery?” box later in this chapter for more information on reporting less than full attendance at delivery services.

May be reported in addition to initial normal newborn ( 99460 ), initial sick newborn ( 99221–99223 ), initial intensive care of the neonate ( 99477 ), or critical care ( 99468 ; 99291 , 99292 ) codes.

Is not reported in conjunction with standby service codes 99026 and 99027 .

When qualifying resuscitative efforts including positive pressure ventilation are provided to a neonate with respiratory or cardiac instability, report 99465 (delivery/birthing room resuscitation, provision of positive pressure ventilation and/or chest compressions in the presence of acute inadequate ventilation and/or cardiac output) instead of 99464 . Do not report both 99464 and 99465 (ie, report only 99465 , when provided).

Refer to Chapter 17 for guidelines for standby service codes 99026 and 99027 . Standby services may be reported with the newborn resuscitation services ( 99465 ) per CPT guidelines. Refer to Chapter 18 for more information on delivery/birthing room neonatal resuscitation and guidelines for coding intensive or critical care services.

➤ A physician is called at the request of an obstetrician to attend a cesarean delivery. The physician stands by until the neonate is delivered and provides stabilization of the neonate, who initially requires blow-by oxygen but steadily becomes more vigorous ( 99464 ). The same physician then provides initial normal newborn care ( 99460 ) on that same day. Teaching Point: The physician separately reports the 2 services. No modifier is reported on codes 99460 and 99464 because the codes are not bundled under National Correct Coding Initiative edits.

➤ A delivering physician asks a neonatologist to be present at delivery of a neonate whose mother has active infection. The neonatologist documents stabilization, including use of CPAP without positive pressure ventilation and a comprehensive examination of the neonate, in addition to review of the maternal and fetal history and discussion with the parents and delivering physician. The newborn is admitted to the newborn nursery under the orders of another physician. This attending physician provides a comprehensive history and examination, orders screening tests and prophylactic interventions, and counsels the family that the neonate will be monitored closely for signs of illness. The physician also counsels about topics such as feeding, sleep, and safety. The attending physician would report 99460 or initial hospital inpatient or observation care ( 99221–99223 ) if the newborn experienced an abnormal transition and required significant intervention(s) on that date. Teaching Point: Although a history and examination were performed, they do not equate to initial hospital care of the newborn. The neonatologist reports 99464 for attendance at delivery.

Refer to the “Stillborn Deliveries and Unsuccessful Resuscitation” box in Chapter 18 for discussion of billing for services provided to a mother and/or neonate when the outcome is stillborn delivery of a neonate or unsuccessful resuscitation of an ill neonate.

There are some important guidelines for reporting conditions that originate in the perinatal period. In ICD-10-CM , these conditions are classified to Chapter 16 and codes P00–P96 . Codes in this chapter are used only on the neonate’s record and not that of the mother.

Following is the order for reporting codes for neonates at the birth hospital:

Birth outcome ( Z38- , reported only by the attending/admitting physician)

Codes from the perinatal chapter ( P00–P96 )

Codes from the congenital anomalies chapter ( Q00–Q99 )

Codes from all other chapters

Other important guidelines include that

Perinatal condition codes are assigned for any condition that is clinically significant. In addition to clinical indications for reporting codes from other chapters, perinatal conditions are considered clinically significant if the condition has implications for future health care needs. Other clinical indications that apply to all conditions are those requiring

— Clinical evaluation (eg, subspecialty consultation)

— Therapeutic treatment

— Diagnostic procedures

— Extended hospital stay

— Increased nursing care and/or monitoring

Should a condition originate in the perinatal period and continue past the 28th day after birth, the perinatal code should continue to be used regardless of the patient’s age.

Typical scenarios that may require exclusive use of perinatal or neonatal codes beyond the perinatal period are those related to care of a critically ill or recovering neonate, such as necrotizing enterocolitis in newborn ( P77.- ), chronic respiratory disease arising in the perinatal period ( P27.- ), and preterm birth ( P07.- ).

Perinatal codes are not reported for conditions with onset after the patient is 28 days old. For example, necrotizing enterocolitis with onset after the neonatal period is reported with K55.30–K55.33 .

If a newborn has a condition that could be caused by the birth process or community acquired, and documentation does not indicate which the cause is, the condition is reported as resulting from the birth process. Community-acquired conditions are reported with codes other than those in ICD-10-CM Chapter 16.

Codes in categories P00–P04 (newborn affected by maternal factors and by complications of pregnancy, labor, and delivery) may be reported when the conditions are suspected but have not yet been ruled out.

If a neonate is suspected of having an abnormal condition that, after examination and observation, is ruled out, assign codes for signs and symptoms or, in the absence of signs or symptoms, a code from category Z05 (encounter for observation and evaluation of newborn for suspected diseases and conditions ruled out).

➤ A neonate was born at 36 weeks’ gestation to a mother whose group B β-hemolytic streptococcal culture result was still pending at the time of delivery . The newborn was alert with excellent Apgar scores in the delivery room and was admitted to the newborn nursery. The newborn was treated per current group B streptococcal disease guidelines, with no indication of illness. On day 2, the mother’s group B streptococcal culture result was negative. The patient was discharged home as a normal newborn. ICD-10-CM . CPT . Day 1: Z38.00 (single liveborn, delivered vaginally), P00.89 (newborn affected by other maternal conditions) Day 1: 99460 Day 2: Z38.00 (single liveborn, delivered vaginally), Z05.1 (observation and evaluation of newborn for suspected infectious condition ruled out) Day 2: 99238 View Large Teaching Point: On day 1, the patient was suspected of being affected by a localized maternal infection ( P00.89 ). Normal initial newborn care is reported rather than hospital care because the neonate, although at risk for infection in this case, was not treated but observed and did not develop infection. By day 2, the condition was ruled out ( Z05.1 ) and discharge day management services were performed ( 99238 ).

Refer to Chapter 17 for full details for selecting and reporting hospital inpatient services 99221–99223, 99231–99233, 99234–99236 , and 99238–99239 .

Levels of hospital E/M services are based on all hospital care services provided on the same date by the same physician or qualified health care professional (QHP) or by multiple physicians and QHPs of the same group practice (billing under the same tax identification number) and same exact specialty. Refer to discussion of split or shared visits in Chapter 6 for information on determining which individual reports a hospital E/M visit that includes work by a physician and a QHP.

When multiple physicians of the same specialty and same group practice provide separate initial or subsequent hospital care to a newborn on the same date, report with a single code representing the combined medical decision-making (MDM) (eg, 99223 , initial hospital inpatient or observation care with a high level of MDM) or combined total time on the date of the encounter.

Report an initial hospital or observation service when the patient has not received any professional services from the reporting physician or QHP or another physician or QHP of the exact same specialty and subspecialty who belongs to the same group practice, during the current admission and stay. Attendance at delivery by the individual does not exclude separately reporting initial hospital care for services provided after admission to the newborn nursery.

Report a subsequent hospital or observation service when the patient has previously received professional service(s) from the physician or QHP or another physician or QHP of the exact same specialty and subspecialty who belongs to the same group practice, during the current admission and stay. Services provided by covering physicians are reported as if provided by the physician who is unavailable.

When a neonate is not treated but only observed for the potential development of illness, normal newborn codes would be reported.

Codes 99221–99223 are used to report the initial hospital encounter with a sick neonate who does not require intensive observation and monitoring or critical care services.

Refer to Chapter 17 and Table 17-2 for the specific coding and documentation requirements for reporting initial hospital care.

➤ The pediatrician sees a newborn boy admitted to the well-baby nursery. The baby’s blood type is O+ and his Coombs test result is positive. He was born to a mother with blood type O− who has a history of 2 previous newborns with jaundice secondary to Rh incompatibility. At 8 hours of age, the neonate appears jaundiced. Total and direct bilirubin tests, CBC, and reticulocyte count are ordered; results are evaluated; the newborn’s risks for kernicterus are discussed with the family; and phototherapy is started. The pediatrician performs a clinically indicated history and physical examination. The physician’s total time on the date of the encounter is 50 minutes. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P55.0 (Rh isoimmunization of newborn) 99222 (initial hospital inpatient or observation care with moderate level MDM or ≥55 minutes of total time) View Large Problem(s) addressed ➟ Moderate (1 acute illness with systemic symptoms ) Data reviewed and analyzed ➟ Moderate (4 unique tests ordered and history required from independent historian) Risk of patient management ➟ Moderate (phototherapy) Teaching Point: When reporting initial hospital care based on MDM, 2 of 3 elements of MDM must be met. In this example, all 3 elements support moderate MDM. Although code P55.0 does not specifically mention “jaundice,” the ICD-10-CM Index entry for newborn jaundice resulting from maternal/fetal Rh incompatibility directs only to code P55.0 .

➤ The pediatrician admits a full-term neonate, born vaginally, with Rh incompatibility (mom AB− and baby B+/Coombs test result positive). The otherwise normal neonate is monitored for elevated bilirubin level. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P55.0 (Rh isoimmunization of newborn) 99460 (initial newborn care) View Large Teaching Point: The neonate is being observed but not treated, supporting 99460 .

Subsequent hospital care codes ( 99231–99233 ) are reported for each day of service subsequent to initial encounter for the newborn who continues to be sick (ie, not a typical neonate but not in critical condition and not requiring intensive observation and interventions).

Refer to Chapter 17 and Table 17-2 for detailed coding and documentation requirements for 99231–99233 .

Report the appropriate code for the highest acuity on each date of service. On subsequent dates when a previously sick neonate is improved and requires no more care than a normal newborn, the subsequent normal newborn care code ( 99462 ) should be reported.

➤ On day 2 of the birth admission, the attending pediatrician provides subsequent hospital care to a full-term neonate, born vaginally, with ABO incompatibility (mom O➕/antibody test negative and baby B➕/Coombs test result negative) . The total serum bilirubin level is elevated. The pediatrician orders phototherapy and follow-up total serum bilirubin and CBC tests. Clinically indicated history, obtained from the parents, and examination are documented. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P55.1 (ABO incompatibility) 99232 (subsequent hospital inpatient or observation care with moderate level MDM or ≥35 minutes of total time) View Large Problem(s) addressed ➟ Moderate (1 acute illness with systemic symptoms) Data reviewed and analyzed ➟ Moderate (1 test reviewed, 2 tests ordered [total serum bilirubin and CBC], and history required from independent historia n Risk of patient management ➟ Moderate (phototherapy) Teaching Point: On day 2, the neonate continues to require therapeutic management, supporting subsequent hospital care.

Dependent on total time involved in the discharge, either 99238 or 99239 (hospital discharge management) is reported when discharge occurs on a day separate from the initial hospital care.

A newborn who dies on the date of birth is not discharged from the hospital. The attending physician should report a code for the level of hospital care provided (ie, initial hospital sick care, intensive care, or critical care) as appropriate. Codes for discharge services are not reported.

When a neonate is transferred to another facility, the physician providing care before transfer reports the appropriate code for the type of care provided on that date (eg, hourly critical care 99291 and, when appropriate, 99292 ) before the transfer, but not the discharge management.

Time must be documented to support 99239 (ie, time of >30 minutes).

Refer to Chapter 17 for more information on discharge management codes 99238 and 99239 .

➤ The physician performs a follow-up visit for a neonate who will be discharged with a home apnea monitor. The parents are counseled on their neonate’s condition and given instructions for home care and follow-up. Forty-five minutes was spent on the floor reviewing the hospital course and expected follow-up and counseling the parents. Diagnoses are newborn delivered vaginally and newborn apnea. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P28.40 (unspecified apnea of newborn) 99239 (discharge management, more than 30 minutes) View Large Teaching Point: Time (45 minutes unit/floor time dedicated to the patient) is the key controlling factor. If time spent in discharge day management is not documented, 99238 must be reported.

A consultation is reported when a physician, other QHP, or other appropriate source (eg, attorney, nonclinical social worker) requests an opinion and/or advice from another physician or QHP. This request must be in writing or given verbally by the requester and documented in the consultation record. The consulting physician evaluates the patient, renders advice, records it, and returns a report to the requesting physician or appropriate source (either in a shared electronic health record [EHR] or by separate written communication).

Codes 99252–99255 are reported for newborn care when the following circumstances are true:

The encounter meets the definition of a consultation.

The encounter is the first face-to-face professional service provided to the patient by the consulting physician or QHP (or another physician or QHP of the same exact specialty and same group practice) during the admission/stay.

A consulting physician’s follow-up visits with a newborn (newly requested consultation or continuing care) are reported as subsequent hospital care ( 99231–99233 ) unless the service meets the requirements for reporting hourly critical care (refer to Chapter 18 for requirements of critical care).

Refer to Chapter 17 for details of the specific reporting, documentation, and coding requirements for inpatient consultations.

➤ At the request of a primary care physician, a neonatologist evaluates a full-term gestation neonate with moderate tachypnea after birth . A detailed history is obtained from the mother, noting that she had a positive group B streptococcal screening result. Review of labor and delivery records reveals that she received 1 dose of intravenous (IV) ampicillin 2 hours before delivery. Because of fetal tachycardia and a non-reassuring fetal heart rate pattern, a cesarean delivery was performed. After birth, the newborn had Apgar scores of 7 and 9 but was noted to have tachypnea with mild substernal retractions. The neonatologist recommends obtaining blood cultures and beginning antibiotics pending the results of the cultures, as well as a follow-up CBC test at 12 hours. The neonatologist counsels the baby’s parents, writes a detailed medical record note, and discusses her recommendations with the attending physician by phone. The attending physician does not want the neonatologist to assume responsibility for all the patient’s care but requests follow-up of the possible infection. At a follow-up visit later that day, the 12-hour CBC and C-reactive protein test results are reassuring, the blood culture result has remained negative, and the tachypnea has resolved. The neonatologist recommends continuing the antibiotics until culture results are negative at 48 hours but otherwise signs off on the case, remaining available for further questions. The neonatologist’s total time on the date of the encounter is 75 minutes. ICD-10-CM . CPT . P00.82 (newborn affected by [positive] maternal group B streptococcus colonization) 99254 (hospital inpatient or observation consultation, with moderate level MDM or total time ≥60 minutes) View Large Problem(s) addressed ➟ Moderate (1 undiagnosed problem with uncertain prognosis) Data reviewed and analyzed ➟ Moderate (3 tests reviewed and/or ordered and history required from independent historian) Risk of patient managemen t ➟ Moderate (IV antibiotics) Teaching Point: Both the level of MDM and total time on the date of the encounter support code 99254 . If the payer policy does not allow payment for consultation codes, the 75 minutes of service supports initial hospital or observation care code 99223 .

➤ At the request of an obstetrician, a pediatric urologist provides a consultation to a family whose male fetus (single gestation) has an enlarged bladder and bilateral dilated ureters in the second trimester of pregnancy based on prenatal ultrasound . The request for consultation is documented by the obstetrician and the urologist. The urologist spends 10 minutes reviewing records of this new patient provided by the obstetrician, including ultrasounds of the fetus before the consultation on the same date. The consultation with the family takes place via a secure, real-time audiovisual connection with the physician in an outpatient clinic and the patient at home. The service includes discussing how the mother’s treatment will be affected (eg, follow-up testing and delivery will occur at a facility with resources that may be required to care for the neonate). The time spent in consultation with the family is 34 minutes. The urologist documents the time spent and a summary of the discussion. Additionally, the urologist discusses ongoing patient management and delivery with the obstetrician via secure messaging. A written report is also produced and sent to the requesting obstetrician with a copy maintained in the patient’s record. The urologist’s total time on the date of the encounter is 65 minutes. ICD-10-CM . CPT . O35.8XX0 (maternal care for other [suspected] fetal abnormality and damage) 99245 95 (outpatient consultation with moderate MDM or total time ≥55 minutes, by telemedicine) View Large Teaching Point: The patient in this example is not a newborn but, rather, the expectant mother. The physician’s total time supports 99245 . Modifier 95 (synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) is appended to indicate that the service met the requirements of a telemedicine service. If the consultation took place in person while the mother was hospitalized, 9925 4 (inpatient or observation consultation with moderate level MDM or total time ≥60 minutes) would be reported.

Code 99418 is reported in addition to a code for a face-to-face E/M service in a facility setting under the following circumstances:

Only in conjunction with highest-level hospital inpatient or observation services ( 99223 , 99233 , 99236 , 99255 ) or nursing facility services ( 99306 , 99310 )

Only when the total time required for the highest level of service in a code category (eg, 99223 for initial hospital or observation care) has been exceeded by at least 15 minutes

Only when the code for the primary E/M service was selected according to the physician’s or QHP’s total time on the date of the encounter

Refer to Table 17-7 for illustration of required total time to report 99418 in conjunction with inpatient and observation E/M services.

Do not report 99418

✖ When the total time on the date of the encounter exceeds the required time of the primary service by less than 15 minutes

✖ For any time spent providing a separately reported service (eg, a procedure or interpretation and report of a diagnostic test)

✖ For any increment of less than 15 minutes beyond the required time of the primary service or the most recent unit of prolonged service

✖ For prolonged services on a date other than the date of a face-to-face E/M service (Refer to 99358–99359 , discussed in the Prolonged E/M Service on a Date Before or After a Direct Service section later in this chapter.)

➤ A physician reports initial hospital care, 99223, according to the required total time of 75 or more minutes. The physician’s total time on the date of the encounter is 95 minutes. The physician reports 99223 and 99418 × 1 unit. Teaching Point: The physician’s total time of 95 minutes exceeds the required time of 75 minutes or more for 99223 by more than 15 minutes. Only 1 unit of 99418 is reported because the initial unit of service for 99418 includes 15 to 29 minutes beyond the total time of the related service.

The Medicare program implemented separate Healthcare Common Procedure Coding System code G0316 for prolonged hospital inpatient service. Verify individual payer policies for prolonged E/M services to identify payable codes and time requirements that may differ from the requirements in CPT .

Prolonged service without direct patient contact ( 99358 , 99359 ) may be reported only in relation to an E/M service when it occurs on a date other than the date of a face-to-face E/M service. Report 99358 and 99359

For non–face-to-face E/M services of 30 or more minutes’ total duration on a single date of service

For prolonged services in relation to any E/M service regardless of whether time was used to select the level of the face-to-face service

When the prolonged E/M service is related to a service during or patient for which (face-to-face) patient care has occurred or will occur and relates to ongoing patient management

Do not report 99358 and 99359 when

✖ An E/M service that is selected according to total time (eg, in-person or telemedicine E/M service) is provided on the same date.

✖ Less than 30 minutes of time is directed to the individual patient on the date of service.

✖ The same time is attributed to another service (eg, medical team conference or interprofessional telephone/internet/ EHR consultation).

➤ An infant will be transferred from a Level III neonatal intensive care unit (NICU), following a 30-day hospital stay, to a community Level II unit to complete recovery before home discharge. The receiving physician spends 1 hour 20 minutes reviewing the extensive transfer records on the evening before the patient arrives at the receiving facility. 99358 (prolonged non–face-to-face services; first hour). 99359 × 1 (each additional 30 minutes). Teaching Point: This service included 80 minutes of prolonged service time on a date when no direct E/M service was provided. Code 99358 represents the first 60 minutes. Code 99359 is reported for the final 20 minutes of prolonged service. If less than 75 minutes of prolonged services were provided, 99359 would not be reported because this code is reported for time that lasts at least 15 minutes beyond the first hour or final 30 minutes.

The AAP Newborn Coding Decision Tool 2024 ( https://shop.aap.org/newborn-coding-decision-tool-2024 ) provides a quick reference to help determine appropriate codes for transitions in care.

During a hospital stay, a newly born or readmitted neonate may require multiple levels of care. A normal newborn may end up becoming sick, becoming intensively ill, or requiring critical care during the same hospital stay. As they improve, recovering neonates require lower levels of care (eg, normal neonatal care) before home discharge.

It is important to remember that

When a patient initially qualifies after birth for normal newborn care and, at a subsequent encounter on the same day, becomes ill and requires a higher service level, normal newborn care ( 99460 or 99462 ) may be reported in addition to the following codes on the same day:

— Initial hospital care ( 99221–99223 )

— Initial intensive care ( 99477 )

— Initial critical care ( 99468 )

— Time-based critical care ( 99291 , 99292 )

CPT instructs to report the appropriate E/M code with modifier 25 for these services in addition to the normal new-born code.

Some payers use code edits that do not allow separate payment of multiple E/M services provided by the same physician or QHP or individuals of the same specialty and same group practice. When normal newborn care will not be separately reported, it may be beneficial to document the time spent providing normal newborn care to a neonate who is being observed for illness. This time may be added to the time of hospital care provided later on the same date and used in selecting the level of initial or subsequent hospital care based on total time on the date of the encounter. It applies only when normal newborn care is not separately reported.

➤ A physician admits a full-term neonate, born vaginally, with Rh incompatibility (mom AB– and baby B➕/ Coombs test result positive). The mother had not received RhoGAM injection during her pregnancy. A complete examination of the neonate is normal in findings, with no hydrops or hepatosplenomegaly. The initial hemoglobin test result is borderline, and the reticulocyte count is elevated. The parents are counseled, and the initial plan is to monitor the bilirubin and hemoglobin levels every 4 hours. The physician documents 30 minutes spent providing normal new-born care. The physician is notified of a rise in the bilirubin level to 10 mg/mL and reevaluates the child. The child’s progress and feeding history are obtained from nurses and parents, and the examination is documented, noting the dermal progression of the jaundice while eliminating any other clinical change. The parents are counseled that the child will require a few days of continued hospital care and phototherapy, which is initiated at the visit. All the parents’ questions are answered. The physician’s total time on the date of the encounter is 75 minutes. ICD-10-CM . CPT . Z38.00 (single liveborn, delivered vaginally) P55.0 (Rh isoimmunization of newborn) 99223 (initial hospital care requiring high MDM or total time meeting or exceeding 75 minutes) View Large Teaching Point: The physician may select the initial hospital care code based on MDM or total time directed to care of the individual patient on the date of service. The documented total time of 75 minutes supports 99223 (assigned 5.73 total relative value units [RVUs] and 3.86 work RVUs). If normal newborn care is separately reported, no time related to provision and documentation of the normal newborn care will be included in the total time of the initial hospital care.

➤ A neonate who was initially normal becomes ill several hours after Physician A provided normal newborn care, so the neonate is moved to a higher level of care. Physician B of another group practice assumes management of the newborn’s care and provides an initial hospital care service with moderate-level MDM. Physician A reports 99460 Physician B reports 99222 View Large Teaching Point: No modifier is required because the physicians are not of the same group practice, although they may each be general pediatricians (eg, a community physician provides normal newborn care, whereas a hospitalist/ neonatologist assumes care of an ill newborn).

Once an initial-day care code for a higher service level has been reported, an initial code for a lower service level within the same hospital stay will not be reported.

— If an ill neonate has required intensive care ( 99477–99480 ) but no longer qualifies for intensive care and is transferred to the care of a physician of a different specialty or different group practice, the receiving physician will report subsequent hospital care ( 99231–99233 ) based on the level of service provided.

— The receiving physician will not report initial hospital care ( 99221–99223 ) for the first encounter after the transfer. If the neonate is no longer ill but requires continued hospital observation, the receiving physician will report subsequent normal newborn care ( 99462 ). If the neonate is still ill but no longer requires intensive observation, the subsequent hospital care codes ( 99231–99233 ) will be reported.

— The transferring physician may report initial neonatal intensive care ( 99477 ) if provided earlier on the date of transfer. But when the ill neonate improves and is transferred on a date after the initial day of intensive care, a transferring physician will report subsequent hospital care ( 99231–99233 ) and not subsequent neonatal intensive care ( 99478–99480 ). The level of care determines the code, not the location of the newborn. Care provided in the NICU does not automatically support intensive care.

➤ A neonate (2,600 g) is transferred from neonatal intensive care by Dr A to Dr B, who is of a different specialty (eg, pediatrician, hospitalist), to complete recovery before home discharge. On the day of transfer, Dr A determines that the ill but recovering neonate no longer requires intensive care and documents 25 minutes spent on the unit/floor arranging the transfer. Dr B provides a face-to-face E/M service to the neonate, documenting 75 minutes of time directed to the patient. Dr A reports 99231 (subsequent hospital care, 25 minutes) Dr B reports 99233 (subsequent hospital care, typical time 50 minutes) 99418 × 1 (direct prolonged services, first 15 minutes) View Large Teaching Point: Dr B may not report initial hospital care for services to the patient who has received prior initial hospital services (eg, initial neonatal intensive care) in the same facility and same stay. The typical time of 99233 was exceeded by 25 minutes, supporting 99418 .

If the circumcision with a clamp or other device is performed without dorsal penile or ring block, append modifier 52 (reduced services) to 54150 .

Medicare has a global period of 0 (zero) assigned to 54150 .

When performing a circumcision and a separately identifiable E/M service on the same day (eg, 99462 , subsequent normal newborn care; 99238 , discharge services ≤30 minutes), append modifier 25 to the E/M code. Link the appropriate ICD-10-CM code (eg, Z38.00 ) to the E/M service and to the circumcision code.

The American Hospital Association Coding Clinic instructs that Z41.2 (encounter for routine and ritual male circumcision) not be assigned during the birth admission, as circumcision is a routine part of the newborn’s hospital care.

Unlike with 54150 , Medicare has a global period of 10 days assigned to 54160 and 54161 . A physician who performs a procedure with a 10-day global period must append modifier 24 (unrelated E/M service by the same physician or other QHP during a postoperative period) to the E/M code for subsequent newborn or hospital care or discharge management (eg, 99238 24 ) provided in the 10-day period following the procedure for general care of the newborn that is unrelated to the procedure.

Refer to Chapter 12 for information on coding for circumcisions performed in the office.

Occasionally, a newborn experiences issues with latching on or sucking effectively because of a tight frenulum. If these issues are severe enough to warrant intervention by incision of the frenulum, report 41010 for lingual frenotomy or 40806 for labial frenotomy. This may be completed in the hospital before discharge. Link ICD-10-CM codes P92.5 (neonatal difficulty in feeding at the breast) and Q38.1 (ankyloglossia) to the procedure code on the claim.

● If the physician performing the incision is also performing newborn care on the same date, be sure to append modifier 25 to the hospital care service also being reported. Link this service to the appropriate Z38 code followed by P92.5 and Q38.1 .

✖ Do not report CPT code 41115 (excision of lingual frenum [frenectomy]) when the frenulum is only incised or clipped.

Codes 94780 and 94781 (car seat testing) are reported when determining whether an infant through 12 months of age may be safely transported upright in a car seat or must be transported by lying down in a car bed.

Car seat testing codes may be reported in addition to the subsequent hospital or discharge day management codes when performed and documented. Note: These codes cannot be reported in addition to critical or intensive care services.

Time spent in car seat testing is not counted as time spent in discharge day management.

Car seat testing may also be provided to an infant in an outpatient setting to determine if the infant can safely move from car bed to car seat transportation.

Refer to Chapter 18 for more information on car seat testing.

To test your knowledge of the information presented in this chapter, complete the quiz found at the end of it, after the resources. Answers to each quiz are found in Appendix III .

This chapter addressed coding for services provided during a newborn’s birth admission. Following are some takeaways from this chapter:

The neonatal period begins at birth and continues through the completed 28th day after birth , ending on the 29th calendar day after birth. The day of birth is considered day 0 (zero).

ICD-10-CM codes from category Z38 are used to report live-born neonates according to type of birth and are the first listed for care by the attending or admitting physician during the entire birth admission.

The choice between coding for normal newborn care and coding for hospital care is based on the physician’s judgment and the type of symptoms demonstrated.

CPT codes for care of a normal newborn typically follow a pathway of daily care from initial care to subsequent care and/or discharge day management.

AAP Newborn Coding Decision Tool 2024 ( https://shop.aap.org/newborn-coding-decision-tool-2024 )

When is a newborn considered admitted to the hospital for the birth?

At the time of birth

When examination in the delivery room begins

When the medical record is created in the delivery room

At the time of leaving the delivery room

Which diagnosis code(s) is reported when a healthy newborn continues to receive daily visits by the attending physician or QHP pending discharge of the mother or foster care placement?

Z76.2 (encounter for health supervision and care of other healthy infant and child).

Only the appropriate Z38 code for the live-born infant, as there is no limit on the length of a normal newborn stay.

An appropriate Z38 code and Z76.2 .

This service is not reported because the patient is healthy.

Which code(s) represents a service provided in the delivery room, at the request of an obstetrician, including attending delivery and stabilization of the newborn with blow-by oxygen before transfer to the normal newborn nursery?

99464 (attendance at delivery and initial stabilization of a newborn)

99465 (delivery/birthing room resuscitation)

99460 (initial hospital care of the normal newborn)

99221–99223 (initial hospital inpatient or observation care)

True or false? Perinatal diagnosis codes may be reported when a condition that originated in the perinatal period continues past the 28th day after birth.

Which code(s) is reported for a follow-up E/M service provided to an ill newborn (not requiring intensive or critical care) by a physician who provided a consultation earlier in the admission?

99231–99233 (subsequent hospital or observation care)

99252–99255 (inpatient or observation consultation)

99221–99223 (initial hospital care)

Either a consultation or an initial hospital care code as determined by payer policy

● indicates a new code; ▲ , revised; # , re-sequenced; ➕ , add-on; ★ , audiovisual technology; and 🔈 , synchronous interactive audio.

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IMAGES

Revisiting Neonatal and Pediatric Critical Care Services
Coding Corner: Annual Wellness Visit Documentation & Coding
What Are the 2022 CPT Codes for Annual Wellness Visits?
Well Child Visit Schedule
CPT Code 99465 for Newborn Attendance at Delivery and Resuscitation
CPT Code Guide

VIDEO

Gucci Mane & Keyshia Celebrate Christmas Eve With Kids Iceland And Ice, Full Of Love And Laughter!🎄
Super cute newborn, the nurse wrapped the newborn well
Newborns tremble violently! The nurse wrapped the newborn well
The Importance of Giving Birth in Health Centers for a Healthy Family
Uh just born...newer mommy holding her newborn well
The nurse wrapped the newborn well, and the newborn was very cooperative

COMMENTS

Coding for Newborn Care Services (99460, 99461, & 99463)
CODES FOR THE INITIAL CARE OF THE NORMAL NEWBORN. 99460. Initial hospital or birthing center care, per day, for E/M of normal newborn infant. 99461. Initial care per day, for E/M of normal newborn ...
CPT CODE 99391, 99395, 99396, 99397, 99394
OVERVIEW. Preventive Medicine Services [Current Procedural Terminology (CPT®) codes 99381-99387, 99391-99397, Healthcare Common Procedure Coding System (HCPCS) code G0402 are comprehensive in nature, reflect an age and gender appropriate history and examination, and include counseling, anticipatory guidance, and risk factor reduction interventions, usually separate from disease-related diagnoses.
PDF CODING FOR Pediatric Preventive Care2022
CPT. code(s) from a physician/other QHP, or another physician/other QHP of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years. CPT. Codes. ICD-10-CM. Codes 99381 . Infant (younger than 1 year) Z00.110 . Health supervision for newborn under 8 days old . or Z00.111 . Health supervision for ...
PDF Pediatric Coding
2. Normal Newborn visit, day 2 3. Discharge normal newborn day 3 _____ 2. 99462 3. 99238-99239 _____ • 99463 • Normal Newborn evaluated & discharged same day 9 Normal Newborn Care • 99460 Initial hospital or birthing center care- normal newborn • 99461 Initial care other than hospital- normal newborn • 99462 Subsequent hospital ...
PDF Quick Tips Coding Well-Child Visits
A child has a well-child visit EPSDT (99381 - 99461), with a well child diagnosis code (Z-code) in the first position; the sick visit code (99211 - 99215) with the modifier 25 and with the illness diagnosis CPT code in the second position. To bill this way, there must be enough evidence in the medical record documentation to support a stand ...
PDF Well-Child Visit Billing Reference Guide
To bill for a well-child visit: Use the age-based preventive visit CPT code and appropriate ICD-10 Code listed in Table 1. Bill for each separate assessment/screening performed using the applicable CPT code from Table 2. If a screening or assessment is positive, use ICD-10 code Z00.121. If it is an issue that requires follow-up or a referral ...
Newborn Coding in the Office or Outpatient Setting
Coding for services provided after discharge from the birth admission often fall into the preventive evaluation and management (E/M) service categories (eg, 99391).However, coding may become more complicated when a well-baby visit includes abnormal findings or a visit is scheduled due to illness or concerns about the neonate's health.
When to use normal care, sick care codes for newborns in hospital
Normal newborn care services are reported with these codes: 99460Initial hospital or birthing center care, per day, for E/M of normal newborn infant. 99462Subsequent hospital care, per day, for E/M of normal newborn. The Coding for Pediatrics manual defines a normal newborn as the following: Transitions to life in the usual manner.
Coding and Reporting Pediatric Preventive Care Services
The relevant CPT and ICD-10 codes for preventive services for new patients are: CPT code 99381 - Infant younger than 1 yearICD-10 codes:Z00.110 Health supervision for newborn under 8 days old orZ00.111 Health supervision for newborn 8 to 28 days old orZ00.121 Routine child health exam with abnormal findings orZ00.129 Routine child health exam ...
CPT® Code 99460
CPT Code 99460, Evaluation and Management, Newborn Care Services - Codify by AAPC. Select. Code Sets; ... View any code changes for 2024 as well as historical information on code creation and revision. ... initial hospital care visit for newborn. I thought 'first time seeing the patient, initial code', but did find a medi-cal reimbursement book ...
A Seven-Step Guide to Neonatal Coding
Office setting: When the pediatrician sees the baby for the first time and the visit occurs in the office, use an office visit code (99201-99205) or preventive medicine services code (CPT 99381 ). If she has been seen previously in the nursery, the infant is an established patient (99211-99215). 2. Look for Resuscitation and Other Billable Services
Use of 99432 Clarified : First-Visit Coding for Normal Newborns
The diagnosis code she uses for this first visit is V30.0 for a newborn born vaginally. A key point to remember is that the 12-month visit often gets denied because too many well-care visits have been used in the first year. This varies from plan to plan, and each states Medicaid program is different as well.
PDF Coding for Preventive Medicine Service Encounters Final
ICD‐10‐CM. CPT. Z00.110 Health exam for NB < 8 days. 99391 Preventive medicine service <1yr. P59.9 Neonatal jaundice, unspecified. 9921X 25 E/M service based on key components. Teaching Point: The codes for routine newborn encounters do not designate between with and without abnormal findings. However, they are still reported based on the ...
CPT CODE 99381, 99382
To bill for a well-child visit: * Use the age-based CPT code (99381-99385; 99391-99395). See Table 1. o Use the following ICD-9 diagnosis codes listed in Table 1 in conjunction with the CPT Code * Bill for each separate assessment/screening performed using the applicable CPT code from Table 2.
Transitioning to 10: Well-Child Office Visits
The tabular list instructs to use an additional code to identify any abnormal findings at these visits. Code Z00.111 is appropriate for a weight check on a patient who is between 8 and 28 days old. For patients aged 29 days and older, the codes for a routine child health examination specify with or without abnormal findings.
Newborn Care or Hospital Care
AAP Pediatric Coding Newsletter (2016) 11 (12): 1-4. 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.
Newborn Care Services 101
99472 - Subsequent Inpatient Neonatal Critical Care, per day, for the evaluation and management of a critically ill neonate, 29 days - 24 months of age. Critical Care Services performed during transport may be reported using 99466 - 99486. Pediatric Critical Care Services (99475, 99476 and 99291, 99292) will be described in a separate ...
Well-Child Visits for Infants and Young Children
Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season ...
Newborn Care Services CPT ® Code range 99460- 99463
Newborn Care Services CPT ® Code range 99460- 99463. The Current Procedural Terminology (CPT) code range for Evaluation and Management 99460-99463 is a medical code set maintained by the American Medical Association. ... 2022 Split/Shared Visits. Am I correct in thinking that the only codes that are allowed to be billed as a Split (or Shared ...
16. Hospital Care of the Newborn
The book's many clinical vignettes, examples, and coding pearls add the guidance needed to ensure accuracy and payment. View a message from Coding for Pediatrics 2023 editor Dr Linda Parsi to learn about using this title in your practice as well as key updates to this year's edition.
Well-child visit (newborn and infant): Clinical sciences
Let's start with the first well-child visit, which occurs during the first week of life, often within 48 to 72 hours after discharge from the hospital. First, check the results of the bilirubin screening, and follow-up as needed. Then assess their development by checking newborn reflexes. Now, here's a clinical pearl to keep in mind!
16: Hospital Care of the Newborn
The book's recently updated vignettes and examples, as well as the many coding pearls throughout, provide added guidance needed to ensure accuracy and payment. Available for purchase at https: ... "Hospital Care of the Newborn", Coding for Pediatrics 2024: A Manual for Pediatric Documentation and Payment, Committee on Coding and Nomenclature, ...
newborn well visits
Best answers. 0. May 23, 2011. #1. newborn. first seen at 4 days old - well visit 99381 v20.2. second visit at 11 days old - well visit doing well but undecended testicles and phimosis discovered...referred to peds urologist ( what should this be?) third visit at 25 days old - well visit 99391 v20.2. My question is what are the time lines for ...