Question Antenatal Newborn Care Performed at First WCC

Mlperkins

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A patient was seen for their newborn WCC. Upon obtaining the Hx, it was found that the mother did not have adequate prenatal care and the child was born at home with no antenatal care. During the WCC, the pediatrician performed the newborn hearing screen, HepB vaccine, vitamin K, eye ointment, and newborn blood draws. All of this would typically be performed immediately post birth. Would an additional E/M LOS be supported with the WCC? Also, what would be the best fit Dx code? I was thinking P00.89, but the mother didn't have any "conditions" other than lack of prenatal care due to personal reasons. This is my first encounter with something like this. Any advice is appreciated!
 
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It appears your physician provided normal newborn care and you could report Z38.1 and 99461 for the service along with appropriate codes for hearing screen, vaccine and administration, vitamin K and administration and any lab tests performed in the office.

I would only code what the physician diagnosed for the newborn. If the newborn is well, despite the mother's lack of prenatal care, I would not assign a code for lack of prenatal care.

Cindy
 

Mlperkins

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It appears your physician provided normal newborn care and you could report Z38.1 and 99461 for the service along with appropriate codes for hearing screen, vaccine and administration, vitamin K and administration and any lab tests performed in the office.

I would only code what the physician diagnosed for the newborn. If the newborn is well, despite the mother's lack of prenatal care, I would not assign a code for lack of prenatal care.

Cindy
Thank you so much! I appreciate your help!
 
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