Wiki Comprehensive HX for a Newborn 99222

[Love Coding!]

Hi all,

It's been a while since I have posted anything, it's great to be back! I have a question, does anyone know if there is literature out there in regards to documentation requirements for a comprehensive history for an initial hospital visit for a newborn?

Are there special guidelines out there when the visit warrants moderate or high medical decision making?

Any insight would be greatly appreciated!

Denise

 

[MikeEnos]

Regarding Medical Decision Making, you can pretty much just use the same tools (Marshfield Clinic) we use for adults. Granted, you should keep in mind the complexity and risk that the provider is dealing with since it is a newborn who requires admission, but I don't think there are any additional tools for MDM in newborns.

For history, it is also the same, but there is one caveat that CMS mentions for newborns. I often get the question from providers, "How can we be expected to get a complete review of systems from a newborn? Is it dishonest for me to document my positives, and pertinent negatives, then use the phrase 'all other systems negative.'?" Well according to CMS, it's OK. They state in their E/M Services Guide:

For certain groups of patients, the recorded information may vary slightly from that
described here. Specifically, the medical records of infants, children, adolescents and
pregnant women may have additional or modified information recorded in each history
and examination area.

As an example, newborn records may include under history of the present illness (HPI)
the details of mother’s pregnancy and the infant's status at birth; social history will focus
on family structure; family history will focus on congenital anomalies and hereditary
disorders in the family. In addition, information on growth and development and/or
nutrition will be recorded. Although not specifically defined in these documentation
guidelines, these patient group variations on history and examination are appropriate.

 

[Love Coding!]

Regarding Medical Decision Making, you can pretty much just use the same tools (Marshfield Clinic) we use for adults. Granted, you should keep in mind the complexity and risk that the provider is dealing with since it is a newborn who requires admission, but I don't think there are any additional tools for MDM in newborns.

For history, it is also the same, but there is one caveat that CMS mentions for newborns. I often get the question from providers, "How can we be expected to get a complete review of systems from a newborn? Is it dishonest for me to document my positives, and pertinent negatives, then use the phrase 'all other systems negative.'?" Well according to CMS, it's OK. They state in their E/M Services Guide:

Thanks Mike! Much appreciated!