Did you assign the appropriate International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedural Terminology® codes for the scenario?

As shown in the Table, Dr Sam provided initial newborn care (99460), subsequent hospital care (99232), discharge day management (99238), and circumcision by clamp with regional dorsal penile block (54150). The entire admission is the birth admission for Baby Joe, so Dr Sam’s first listed diagnosis each day is Z38.00 (single liveborn, born in hospital, delivered vaginally). Dr Sue provided an inpatient consultation (99253).

On March 2, Dr Sam diagnosed transitory neonatal hypoglycemia (P70.4), and this is reported secondary to code Z38.00. The subsequent hospital care on this date is reported with 99232. Code 99233 would require 2 of the following 3 key components: detailed history, detailed examination, and high-complexity medical decision-making.


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