Pediatric Coding Alert

You may never say hello to the $75 for 99463 unless you're vigilant about meeting the insurer's same-date interpretation.

Code 99463 specifically states E/M of normal newborn infant admitted and discharged on the same date. Does same date mean the hospital admission date of service has to match the initial h&p note and discharge?

Here are two ways policies may view same date. Use 99463 When Hospital, H&P Dates Match Turns out a literal approach to interpreting the sameday admit and discharge code can head off a stack of denials. One Ohio hospital is knee deep in denials for 99463 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant admitted and discharged on the same date) with two dates of service:

• one for the hospital admission

• one for the history and physical (h&p) and discharge.

Medicaid allowed us to use this code to encourage the Amish to have hospital deliveries, rather than home births, relates Julia M. Pillsbury, DO, FAAP, FACOP, founder and president of The Center for Pediatric and Adolescent Medicine, P.A. in Dover, Del. "After the delivery, we admitted the newborn, and provided all was well, discharged the baby later that day."

Example: "A mother delivers her third child vaginally in a birthing room at a hospital after an uncomplicated pregnancy. The office is notified of the birth and told that the mother wishes to take the newborn home later that day. The physician comes to the hospital in the early evening and completes the admission and discharge examination and the hospital paperwork during that single, same-day hospital visit. All of the mother's questions are answered, and a follow-up appointment is established in the office in 48 hours."

Advice: "Code 99463 should be reported because the initial care and discharge services were provided on the same day of service," according to Coding for Pediatrics 2009, Chapter 4: Care of the Neonate and Critically Ill Child (page 106).

Recent guidance, however, may also indicate that a more consistent approach to same date might be appropriate. "There's been increased scrutiny of 99463's application because it has the same language as observation codes 99234-99236, which similarly stipulate 'admission and discharge on same date,'" Pillsbury says.

New Medicare same-day observation admit and discharge guidelines require the physician provide the face-to-face admission to observation and face-to-face discharge on the same calendar day. You base your admission and discharge dates on when the physician saw the patient, not on the hospital's admission dates.

Reality: Admission date and hospital admission date mismatches are possible and may be appropriate. Suppose a child is admitted to the hospital at 10 p.m. through the emergency room and the pediatrician doesn't see the child until the next day when the doctor does the admission.

The face-to-face day is the date that you have to put on the claim as your admission date, says Donelle Holle, RN, principle of Pedscoding.com in Indiana. Analysts are applying the same logic to 99463. "Code 99463 is to be used when a normal newborn is initially seen and also discharged on the same day of service," Holle says. When the pediatrician performs the services on different days, report the individual normal newborn care (99460, Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) and discharge (99238, Hospital discharge day management; 30 minutes or less ...; or 99239, ... more than 30 minutes) codes.

Example: A pediatrician finishes rounds at 8 a.m. and a newborn is born at 9 a.m. When the pediatrician first sees the patient on rounds the next day, the newborn is almost 24 hours old. The pediatrician performs the normal newborn assessment, during which the mom requests to go home the same day. The pediatrician says she can go home later that evening provided the baby continues to have wet diapers, have stools, and is nursing or bottle feeding. The physician then writes orders for the infant's discharge and also writes the discharge note. In this case, report 99463 to represent the same-day assessment and discharge. "Even though the infant was born the day before, the services were performed on the same date of service," Holle explains.

You'll get approximately $50* less for using the combination code (99463, 2.09 relative value units [RVUs]), rather than reporting the individual admission (99460, 1.56 RVUs) and discharge (99238, 1.84 RVUs) codes. Code 99463 has increased reimbursement ($75) compared to 99460 ($56) to represent the included discharge. Because the discharge is somewhat combined with the assessment work, 99463 pays less than reporting the individual codes together, which combined pay approximately $122.63. *Figures are based on the 2009  Medicare Physician Fee Schedule that pediatricians can use to gauge private payers' rates.

Stay tuned to Pediatric Coding Alert for updates on 99463 as information becomes available.