Pediatric Coding Alert

Coders are often unsure whether to bill a normal newborn or hospital admission code for a newborn with a minor problem. The normal newborn code (99431, history and examination of the normal newborn infant, initiation of diagnostic and treatment programs and preparation of hospital records. [This code should also be used for birthing room deliveries.]) pays better than the lowest level of the three hospital admission codes (99221-99223), but codes should not be chosen based on reimbursement. If there is a problem even a minor, common one such as jaundice requiring treatment with bili lights the baby is not normal and a hospital code should be used.

The dilemma may continue into subsequent days, when the pediatrician may have to choose between a normal newborn code (99433, subsequent hospital care, for the evaluation and management of a normal newborn, per day) and subsequent hospital care (99231-99233). Again, the question is whether the baby is normal. For example, a baby may be normal at delivery thus warranting 99431 with jaundice developing the second day necessitating a switch to the hospital care codes. If the jaundice decreases by the third day, return to the normal newborn codes, billing 99433.

The test to determine if the baby is normal, according to CPT Codes editorial panel member and vice president and medical director of Childrens Hospital and Regional Medical Center in Seattle, Richard A. Molteni, MD, FAAP, is whether one of two conditions is met:

(1) Is any additional physician work expected? or

(2) Is the baby removed from the mothers room or the normal nursery and admitted to an observation or intermediate-level nursery?

If the answer to either of these questions is yes, do not use normal newborn codes.

In general, both jaundice and an untreated fractured clavicle would qualify as normal, Molteni says. Only if the jaundice exceeds physiological levels and requires treatment and a new diagnosis would the hospital subsequent care codes be used. If the fractured clavicle doesnt call for treatment and it rarely would it, too, would fall in the normal category.

Another gray area (in coding, but not clinical, terms) is a supernumerary digit. The pediatrician treats this by ligation (11200) as a separate procedure, but the baby would definitely still be a normal newborn. An extra finger or toe might not sound normal, but it is when choosing between normal newborn and hospital admission codes.

Two other codes used for newborns 99436 (attendance at delivery) and 99440 (newborn resuscitation) may help determine whether to bill a normal newborn code or a hospital code at admission. If called to attend a delivery (99436), the pediatrician may find that the newborn has a problem. If newborn resuscitation must be provided, the newborn may or may not transition to normal: Use the hospital care codes (99231-99233), the normal newborn code (99431) or even the initial neonatal intensive care code (99295). If you resuscitate, choose your admission code (normal or hospital) by the babys status after resuscitation, not before.

Code Choice Rests With Medical Decision-making

When a physician is concerned about a problem with the patient, the encounter is no longer for a normal newborn, says Sharon A. Solum, LPN, CPC, billing compliance specialist with MeritCare Health System, a Fargo, N.D., multispecialty hospital and outpatient system with 30 pediatricians. Concern, Solum says, comes down to medical decision-making because the normal newborn code, by definition, includes a history and examination. If there isnt enough medical decision-making to justify a hospital admission code, use a normal newborn code.

Garnet Dunston, CPC, of Dunston Enterprises in Bouse, Ariz., agrees. Even if the problems are minor, its still not a normal newborn, she says. And choosing the normal newborn code over a hospital care code because the former pays better is fraudulent, she says. Any of the payers will go after a physician who does that. She argues, however, that jaundice, at least in her book, is normal and something seen in almost every baby.

But jaundice, although relatively common, could be something serious, cautions Dari Bonner, CPC, CCS-P, CPC-H, president and owner of Xact Coding & Reimbursement Consulting, Port St. Lucie, Fla. If you are treating a problem, the baby is no longer considered normal, and that means you should use the hospital admission or subsequent codes even if they pay less than the normal newborn code.