• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten your username or password use our password reminder tool. To start viewing messages, select the forum that you want to visit from the selection below..
  • Important Note: We will be performing a scheduled maintenance on 1st November 2020. The site will be offline from 7:30PM (MT) till midnight. We apologize for any inconvenience this may cause.

Newborn Criteria for coding consults


Best answers
Newborn Criteria for coding consults


I work for a pediatric specialty group. The doctors from each specialty also work closely with a children's hospital. We code the inpatient consults for the different specialties.

My question stems from the fact that whenever a child is less than 28 days old, we were told that if the physician documented pregnancy and birth history, this qualified for a complete HPI, review of systems, and past medical history. Also, documentation of the mother's prior pregnancies, i.e. para, gravida would suffice for social history. Any hereditary or congenital conditions supports the family history.

Based on this, we have been taught that less is required on newborn documentation to support a comprehensive HPI.

I was hoping to get some feedback as to whether or not other coders followed this guideline. If you do, can you please cite your source as to where these guidleines are documented. (CMS guidelines, journals, ect.)

Thank you for your help.