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.