Primary Care Coding Alert

The latest version of the Correct Coding Initiative (CCI) has an edit that FP coders should note - especially if the practice treats newborn patients.

Get to know the new CCI 16.1 edit and get ready to observe it with this expert breakdown. Check Column 1 on These Hospital E/Ms According to CCI 16.1, these codes are in column 1 of the mutually exclusive edits:

99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: a problem focused interval history; a problem focused examination; medical decision making that is straightforward or of low complexity ...)

99232 (... an expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity ...)

99233 (... a detailed interval history; a detailed examination; medical decision making of high complexity ...).

Column 2 of these edits includes these codes:

99460 (Initial hospital or birthing center care, per day,for evaluation and management of normal newborn infant)

99461 (Initial care, per day, for evaluation and management of normal newborn infant seen in other than hospital or birthing center)

99462 (Subsequent hospital care, per day. for evaluation and management of normal newborn).

Translation: An FP may not report both normal newborn care and subsequent hospital care for a newborn on the same date of service. If the FP performs normal newborn services (99460-99462) on the same date that the newborn later becomes ill and receives subsequent hospital care (99231-99233), you should only report a code from the 99231-99233 code set, explains Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan.

The services are mutually exclusive because the newborn care codes (99460-99463) are for "normal" newborns (i.e., newborns without medical problems); whereas the subsequent hospital care codes (99231-99233)are for problem-oriented services, Moore says.

Since both sets of services are designated as "per day,"coders must choose between them for a given patient on a given date. "Consistent with the mutually exclusive nature of these services, CCI does not permit a modifier to override the edits," Moore continues.

Bottom line: Never report 99460-99262 and 99231-99233 for the same patient on the same date of service.