Coding for services provided after discharge from the birth admission often fall into the preventive evaluation and management (E/M) service categories (eg, 99391). However, coding may become more complicated when a well-baby visit includes abnormal findings or a visit is scheduled due to illness or concerns about the neonate’s health.

For most newborns, the 3- to 5-day visit is the first of the outpatient preventive E/M or well-baby services they receive. These encounters are reported based on whether the patient is a new or an established patient. The newborn is an established patient if any physician of the same group practice and specialty has provided a face-to-face service to the newborn in any setting (eg, newborn care in the hospital).

International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes for newborn preventive visits are age-based and do not indicate the presence or absence of abnormal findings....

You do not currently have access to this content.