Pediatric Coding Alert

99431 or Hospital Admission Codes?: Coding for Newborns, Not Normal, But Not Sick Enough for NICU Codes

- Published on Thu, Apr 01, 1999
When a baby is born with some kind of a problem, but the problem isnt severe enough to use the neonatal intensive care codes (99295-99298), should you use the normal newborn care code (99431) for the first examination, or should you use an initial hospital care code (99221-99223)? You cant report bothyou have to choose between one or the other.

This question comes up often, says Kim Rockwell, ART, CCS, CCS-P, coding auditor for Baylor Health Network in Dallas, TX, which has about 20 pediatricians. If an infant is high-risk, but not sick, then they fall into the category of normal, says Rockwell. Its up to the pediatrician to make the decision: Is it a sick newborn, or is it a normal newborn? You dont use the hospital care codes for a high-risk newborn who isnt sick, she stresses.


If the baby is sick, you should use the hospital care codes, says Rockwell. But she adds that the diagnosis needs to support the use of the hospital care codes. It could be as simple as a fever, she says.

This question was raised recently at Cumberland Pediatrics, a two-pediatrician practice in Somerset, KY. A baby was running a fever at the time of birth. She was not critically ill, but she was sick, says office manager Joy Campbell. How do I code that? Code 99431 is for a normal newborn.

In fact, fever (780.6 ) is a diagnosis which would warrant the use of the hospital care codes, says Richard H. Tuck, MD, FAAP, who is with PrimeCare Pediatrics in Zanesville, OH. Fevers in newborns usually warrant blood cultures, lumbar punctures, and more, says Tuck, noting that the pediatrician must rule out sepsis. This would be serious enough to use 99222 or 99223, says Tuck. (See descriptions of the hospital care codes on page 31.)

Another problem of newbornsand one which is more common than feversis tachypnea. This warrants a sepsis workup, treatment with oxygen, intravenous fluids, and antibiotics, the pediatrician says. Its definitely not neonatal intensive care, but its also not normal. So for transitory tachypnea of the newborn (770.6), you would use the hospital care codes.

Variations of Normal

Normal is what it says: normal, Tuck stresses. Once a baby does anything that is abnormal, you shouldnt use 99431. But there are variations of normal, which should not warrant a hospital care code. For example, many newborns have certain rashes, such as erythema toxicum [778.8], says Tuck. There are different shapes of the head, or a supernumerary digit. These are not conditions which call for a hospital care code, Tuck believes.

What about jaundice? Jaundice is where it gets ambiguous says Tuck. For the typical physiological jaundice, I would still consider that normal, [...]

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