Pediatric Coding Alert

Question: What documentation is necessary to code subsequent hospital care (99433)?

Ohio Subscriber

Answer: Normally, hospitals employ a standard sheet for healthy newborns, and this template may be used to document all necessary services, such as weight and height check and physical exam. Remember, however, that 99433 (subsequent hospital care, for the evaluation and management of a normal newborn, per day) is for a healthy newborn only. If the pediatrician discovers abnormalities or problems during the visit, code a regular hospital visit for subsequent care (i.e., 99231, 99232 or 99233).

Note: CPT does not define what services are necessary to code 99433. Therefore, any documentation that demon-strates the physician delivered services to the newborn on a subsequent day will be sufficient to justify the claim.