Pediatric Coding Alert

Secret: Look to exam, discharge date - not birth date - when assigning 99435

Despite conflicting information on newborn care code 99435's applicable service date, you can report the code on day one or on a subsequent day.

After one coder requested clarification regarding 99435's descriptor, Pediatric Coding Alert discovered that the history-and-exam code confused even experts. Here's the lowdown on what this code means.

Coding Sources Contradict Each Other

If you've tried to answer 99435's date dilemma, you may point to sources that restrict the code to a birthday discharge or expand it to include additional days. In fact, experts cited contradictory information in response to the following scenario:

Case study: A baby is born in the hospital on day one. On day two, when the pediatrician sees the infant for the first time, she performs a history, exam and physical. She then discharges the newborn.

Question: "Should I submit the encounter with 99431 (newborn exam) and 99238-99239 (discharge) or 99435?" asks Charlotte T. Tweed, CPC, coder at Hospital Florida in Orlando. Grab your CPT and Coding for Pediatrics manuals and see if you know how to code her scenario before reading on.

CPT Implies Both

Perhaps you looked in CPT and found documentation that leads you to code the above encounter as 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]) and 99238-99239 (Hospital discharge day management; 30 minutes or less; ... more than 30 minutes). If you did, you're not alone.

Why: You could use CPT's E/M section to bolster your view that you should report 99435 (History and examination of the normal newborn infant, including the preparation of medical records [this code should only be used for newborns assessed and discharged from the hospital or birthing room on the same date])only when a newborn goes home on his birthday.
 
Under "Newborn Care," the third paragraph states you should use 99435 for newborns "admitted and discharged on the same date," says Diane M. Minard, CPC, pediatrics coding adviser for Children's Hospital at Dartmouth in Lebanon, N.H.

The admission date is the date-of-birth. Therefore, CPT's sentence implies that you should report 99435 only for babies whom the pediatrician discharges on their date-of-birth, Minard reasons.

Conflict: The same CPT section also suggests that you could use the code on a following date, such as day two. Code 99435's description says "assessed and discharged on the same date," Minard says.

The phrase suggests that only the assessment and discharge must occur on the same date - not the admission. So if, as in the example, a pediatrician didn't see a newborn until day two, on which day the physician examined and then discharged the baby, you could assign 99435.

Pediatric Coding Corner Says Yes and No

To resolve the discrepancy, maybe you looked up the code in Coding for Pediatrics. But you can also use this source to support either coding answer.

Once again, you'll find fuel for the birth-date argument if you look under "Subsequent Hospital Care Codes" in Coding for Pediatrics. The American Academy of Pediatrics (AAP) publication says to use a single code (99435) "when the neonate is "admitted and discharged on the same date."

You could interpret the statement to indicate that 99435 applies to day-one discharges only. Because the date-of-birth is always the admission date, these service dates will only coincide when the pediatrician admits and discharges the newborn on his birthday.

But if you read another 99435 entry in Coding for Pediatrics, you're back at square one. The "Coding Questions and Answers" section indicates you could use 99435 in the above case study. "If the newborn was initially examined and discharged on the same day, you should report 99435," states Coding for Pediatrics, page 350 (2002, 2003 versions). If the newborn was "not examined until the next day (and discharged on this day), you should still report 99435."

That statement makes it clear that the AAP intends 99435 to apply to same-day exams and discharges, rather than same-day admits and discharges.

Day-One Restrictions Reduce Pay, Code Use

These four conflicting pieces of information, however, may leave you searching for a definitive answer.

Coders have developed their own strategies for solving the admit/discharge date dilemma. "We've always played it conservatively," Minard says. The Children's Hospital at Boston has always reserved 99435 for a neonate whom a physician admits and discharge on the same date, with the admit date being the date-of-birth.

Reimbursement hang-up: Another coder, however, points out a potential payer problem that could arise from following the same-day exam and discharge interpretation. If you assume CPT restricts 99435 to admission day one, when you have a situation in which you examine and discharge a patient on day two, you will have to report two E/Ms (99431 and 99238-99239) on the same day, a combination that most insurers will deny, says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association with 11 pediatric offices in California.

In fact, if you had to reserve 99435 for day one, you would hardly use the code. "Pediatricians rarely send a neonate home the day he's born," says Richard Tuck, MD, FAAP, a member of the AAP national committee on coding and nomenclature. "In addition, CPT's language, 'assessed and discharged ... on the same day,' supports performing those services on a day other than the hospital admission day."

Admission Refers to First Exam's Service Date

And indeed 99435 is appropriate on additional days. You should use the code anytime a pediatrician performs an "admit" and discharge on the same calendar day, says Linda Walsh, MAB, senior health policy analyst with the AAP Division of Health Care Finance and Practice. The problem, however, is that key term: admit.

Rethink "admit" definition: Patients and physicians interpret the admit day differently. A patient considers the admission day to be the day he enters the hospital. For a newborn, the admission day is the day he is born. But a physician counts the admit day as the day she first sees the infant in the hospital.

Which day should you use when determining if a physician performed a same-day admit and discharge? "Coding is always from the perspective of the reporting physician and not the patient," Walsh says. So you should use the day the pediatrician first sees the inpatient as the admission day. Then, if the physician also discharges the newborn on the same day, you should report 99435.

Scenario answer: In the case study, because the admit and discharge occur on the same calendar day, you should report 99435 for both pieces of work. Even though the patient is born on day one (patient's admit day), the pediatrician doesn't see the neonate to perform the exam until day two (coding admission day) on which day she also discharges the patient.