Newborns are the only patients who are admitted to a hospital and may never develop a medical issue or problem and may transition to life in a routine and healthy way.
Coding for newborn services is complex. A newborn will fall under one of four clinical indicators for procedural coding: normal, sick, intensive or critical.
This article focuses only on the nuances between normal care and sick care for babies born in the hospital whose discharge date is subsequent to their initial service date. Intensive care and critical care services are not addressed.
Normal newborn care services
Per the Current Procedural Terminology (CPT) manual, Evaluation and Management (E/M) services for the(normal) newborn include maternal and/or fetal and newborn history, newborn physical examination(s), ordering of diagnostic tests and treatments, meetings with the family, and documentation in the medical record.
Normal newborn care services are reported with these codes:
99460Initial hospital or birthing center care, per day, for E/M of normal newborn infant
99462Subsequent hospital care, per day, for E/M of normal newborn
The Coding for Pediatrics manual defines a normal newborn as the following:
Transitions to life in the usual manner.
May require delivery room intervention but is normal after transition.
May require some testing or follow-up assessment (e.g., bilirubin, complete blood cell count, culture).
Does not require significant intervention.
May be observed for illness but currently does not exhibit any signs or symptoms of the disease.
May be late preterm but requires no special care.
May be in house with sick mother/twin.
It is important to note that some babies may have an International Classification of Diseases, Tenth Revision, Clinical Modification abnormal diagnosis or an observation diagnosis reported but still may qualify for normal newborn care.
A baby born at 38 6/7 weeks’ gestation has ABO incompatibility. The physician is following serial bilirubin levels, but the baby is not on phototherapy. The patient transitions well and no further intervention is required as bilirubin levels remain within normal limits. The baby is coded as a normal newborn.
A baby was born at 39 weeks to a mother with a positive prenatal history of narcotic use. The baby is diagnosed with in-utero narcotic exposure but remains asymptomatic. The patient is being followed for any adverse symptoms but is rooming with mom. The baby is coded as a normal newborn.
Sick newborn care services
Some babies have clinical indications that require more work and medical decision-making than is required for a normal newborn but do not require intensive care. Their care is reported with the following sick newborn hospital care codes:
99221-99223* Initial hospital care, per day, for the evaluation and management of a patient
99231-99233* Subsequent hospital care, per day, for the evaluation and management of a patient
*Reported based on meeting or exceeding the required key elements or based on time per the CPT code descriptors.
A baby was born at 39 weeks’ gestation to a mother who is positive for syphilis. The baby is asymptomatic but is at risk for developing congenital syphilis. The baby has been placed on daily penicillin dosing and remains with the mother in the well-baby setting. The baby’s care is coded with a daily hospital care code.
A baby was born at 39 4/7 weeks’ gestation to a mother who developed gestational diabetes. At 12 hours of age, a blood sugar test reveals hypoglycemia. The physician orders oral glucose and discusses extra feedings with the nursing staff and mom. The sugar levels are ordered to be taken more frequently. After a couple more feedings, the blood sugar levels normalize. This would be coded with a daily hospital care code.
It is important to recognize that newborns may have transitory issues that require observation but will resolve without intervention. Those conditions can present in a normal newborn. Babies who require hospital care services will require additional medical decision-making and are more at risk for morbidity.
The vignettes above are meant to be vague. Co-morbidities or other circumstances can change how a newborn needs to be treated and managed. Always code based on documentation and what is medically necessary for the baby.
Vitaliya M. Boyar, M.D., FAAP, David M. Kanter, M.D., M.B.A., FAAP, and Edward A. Liechty, M.D., FAAP, contributed to this article.