Good morning to all... I am now performing auditing on Newborn charts (new to auditing this area)for correct coding levels and appropriate documentation for billing by our Hospitalist group and I have a question in regards to correct documentation.

For some newborns, the Hospitalists are billing 99464 and also 99460 on the same day. Is there any guidelines on what documentation is required to bill these codes? I have some docs writing one note with a statment saying they attended the birth at the request of the delivering doc, but nothing much and this is combined in the same note for the initial hospital eval.

Should there be two separate notes or is there certain criteria that must be documented for each code to bill? Also, would a -25 modifier need to be attached - and if so, which code?

Thanks in advance for the help!