Primary Care Coding Alert

Question: A mother presents with her newborn baby and says she is concerned about the baby -choking,- or spitting up frequently after she has been fed. The FP performs a level-three established patient evaluation and management service on the newborn. What diagnosis code should I use? I was thinking 933.1, but this code does not seem very accurate.


Oregon Subscriber

--Choosing 933.1 (Foreign body in pharynx and larynx; larynx) should have given you pause because there is a diagnosis code that better represents this patient's condition. On the claim, you should instead assign 779.3 (Feeding problems in newborn), which includes regurgitation of food in newborns.

 For the E/M service, report 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...).

Answers to You Be the Coder and Reader Questions reviewed/provided by Daniel S. Fick, MD, director of risk management and compliance for the College of Medicine faculty practice at the University of Iowa in Iowa City; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.