Pediatric Coding Alert

Scrutinize the notes for discrepancies before selecting your code.

Although you might have CPT® code 99460 committed to memory, that doesn’t mean it’s always the right choice for your pediatrician’s newborn care services. 

The reality is that not every newborn experience should be classified as “normal” --and if your doctor’s notes are missing additional information that goes beyond the statement “normal newborn care,” you could be missing out on additional reimbursement that you deserve.

‘Normal’ Care Refers to No Additional Diagnoses

A “normal” newborn has no abnormal medical conditions or need for special care. Report a normal newborn’s history and examination with 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant).

Initial newborn care for a normal infant typically includes a maternal and/or fetal and newborn history; a newborn physical examination; ordering diagnostic tests and treatments; meetings with the family; and documentation in the medical record.

Diagnosis tip:When billing with 99460 for a single newborn, you’ll typically include diagnosis V30.xx (Single liveborn…). Under ICD-10, V30, this will change to the Z38.xx series. For instance, V30.00 (Single liveborn, born in hospital, delivered without mention of cesarean section) will crosswalk to Z38.00 (Single liveborn infant, delivered vaginally). 

Add-ons: Procedures such as circumcision (54150, Circumcision, using clamp or other device with regional dorsal penile or ring block or 54160, Circumcision, surgical excision other than clamp, device, or dorsal slit; neonate [28 days of age or less]) are not included with the normal newborn codes (99460-99463). These codes have zero day global periods. Be sure to code a circumcision in addition to the newborn care when this procedure is performed.  Also remember that a circumcision is a procedure and needs to be documented as one noting how the procedure was performed, the results and how it was tolerated. To indicate 99460-99463 is significantly identifiable from the minor E/M included in surgical codes, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99460-99463.

Sick Newborn Needs Inpatient Codes

When the pediatrician provides E/M services for newborns who are not considered “normal,” CPT® directs you to report the codes for hospital inpatient (99221-99233), neonatal intensive (99477-99480), or critical care (99468-99476) services.

A baby considered a “sick” newborn might have a fever, high hemoglobin count, or mild respiratory distress, among other issues. For a sick newborn, you’ll select from 99221-99223 (Initial hospital care, per day, for the evaluation and management of a patient ...) for the first day of care, based on the level of history, examination, and medical decision making.

Example: A term newborn is born to a mother with fever and prolonged rupture of membranes. The baby is born with a fever and mild tachypnea. Oxygen saturations are good. The pediatrician orders a culture and initiates IV antibiotics for the newborn. Report services for the initial day of the sick newborn’s care with the appropriate choice from 99221-99223.

Intensive Care Requiring Extra Monitoring

Sometimes infants and neonates are not critically ill but need intensive cardiac or respiratory monitoring, continuous and/or frequent vital signs monitoring, heat maintenance, nutritional adjustments, or laboratory and oxygen monitoring. These babies also require constant observation by the health care team under direct physician supervision.

In these situations, remember that the level of care delivered—not the site of service—determines the code you choose. Intensive care codes could apply to a baby in the newborn nursery or NICU.

Example: An infant is born at 37 weeks gestation with mild tachypnea and requires 30 percent O2 by nasal cannula. The pediatrician acquires cultures and initiates IV antibiotics. Close monitoring is maintained; no additional intervention is indicated.

For the first day of this baby’s care, report 99477 (Initial hospital care, per day, for the evaluation and management of the neonate, 28 days of age or younger, who requires intensive observation, frequent interventions, and other intensive care services). Additional days should be coded according to the infant’s status as follows:

If the neonate continues to require intensive monitoring, frequent interventions, observation, or other intensive care services, use the low birth weight or recovering infant codes. Choose from 99478-99480 (Subsequent intensive care, per day, for the evaluation and management of the recovering infant ...), based on the infant’s weight—and don’t forget that the weight has to be documented for each day that these codes are utilized.

If the child is still ill but no longer requires intensive or critical care services, select from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient ...). Remember that these codes require two of three key factors: history, physical and medical decision making.

Sometimes a child moves from being intensively ill to being ill, to being well. Once the child is well, turn to 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn).

Critical Care Codes Follow Days

Neonates are classified as meeting critical care status when they have organ system failure or progression of organ system failure such as severe respiratory distress, hypotension, or sepsis.

Example: A 32-week premature infant develops moderate respiratory distress and requires treatment of premature lung disease (RSD, respiratory distress syndrome) and nasal CPAP. Respiratory failure rapidly progresses and the physician initiates ventilator treatment.

As with intensive care coding, you have one code for the initial day of neonatal critical care treatment and additional codes for subsequent days. Start with 99468 (Initial inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) and report 99469 (Subsequent inpatient neonatal critical care, per day, for the evaluation and management of a critically ill neonate, 28 days of age or younger) for each additional day.

Remember: If a normal or ill newborn becomes critically or intensively ill subsequent to the initial H&E or hospital admission, treat the ICU or NICU admission as initial. You should always code for an “initial” day of critical care or intensive care before you use a “subsequent” day code. In other words, a patient cannot go from a “regular” or sick first or second day code to a subsequent critical or intensive care code.