newborn well visit icd 10

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Mother’s health*, transitioning to 10: newborn and infant visits.

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American Academy of Pediatrics; Transitioning to 10: Newborn and Infant Visits. AAP Pediatric Coding Newsletter September 2014; 9 (12): No Pagination Specified. 10.1542/pcco_book125_document003

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Pediatricians will probably be remembering many International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for years to come, well after they are no longer reported. And of these, probably none will be more memorable than the most common reason for visits, the V20 diagnosis codes associated with well-child visits. For International Classification of Diseases, 10th Revision, Clinical Modification ( ICD-10-CM ), the preventive medicine codes have been expanded to include 6 characters beginning with the letter Z (Table 1).

The ICD-10-CM tabular list instructs that codes for an abnor­mal finding at the well-newborn or well-child encounter are also reported. Additional diagnosis codes for abnormal findings may be reported when applicable, even when the problem does not require significant evaluation and management (E/M) in addition to the preventive medicine service provided.

Codes from category P07, disorders of newborn related to short gestation and low birth weight, not elsewhere classified, are for use for a child or an adult who was premature or had a low birth weight as a newborn and this is affecting the patient’s current health status (Table 2).

a Includes the listed conditions, without further specification, as the cause of morbidity or additional care, in newborn; excludes low birth weight due to slow fetal growth and fetal malnutrition ( P05.- ); weight is sequenced before gestational age when both are available.

The following list is a translation of the ICD-9-CM codes for diagnoses included in the American Academy of Pediatrics coding guidance, “Supporting Breastfeeding and Lactation: The Primary Care Pediatrician’s Guide to Getting Paid” ( www2.aap.org/breastfeeding/files/pdf/coding.pdf ). Codes in this list describe many conditions common to the newborn and infant. The list also includes codes for conditions of the mother when associated with lactation. (This list is not all-inclusive; please check an ICD-10-CM coding manual or online reference for additional information when reporting these conditions.)

See also the diagnoses associated with size and maturity included in Table 2.

When the original reason for visit has resolved, report also codes in categories Z86–Z87 to indicate personal history of disease.

*ICD-10-CM O codes represent conditions of the mother in pregnancy, childbirth, and the puerperium and are reported only on claims for care of the mother. E/M of conditions of the mother should be separately documented outside the newborn record and reported only on claims for services to the mother (ie, not the newborn).

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Family Life

AAP Schedule of Well-Child Care Visits

Parents know who they should go to when their child is sick. But pediatrician visits are just as important for healthy children.

The Bright Futures /American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the " periodicity schedule ." It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence.

Schedule of well-child visits

• The first week visit (3 to 5 days old)
• 1 month old
• 2 months old
• 4 months old
• 6 months old
• 9 months old
• 12 months old
• 15 months old
• 18 months old
• 2 years old (24 months)
• 2 ½ years old (30 months)
• 3 years old
• 4 years old
• 5 years old
• 6 years old
• 7 years old
• 8 years old
• 9 years old
• 10 years old
• 11 years old
• 12 years old
• 13 years old
• 14 years old
• 15 years old
• 16 years old
• 17 years old
• 18 years old
• 19 years old
• 20 years old
• 21 years old

The benefits of well-child visits

Prevention . Your child gets scheduled immunizations to prevent illness. You also can ask your pediatrician about nutrition and safety in the home and at school.

Tracking growth & development . See how much your child has grown in the time since your last visit, and talk with your doctor about your child's development. You can discuss your child's milestones, social behaviors and learning.

Raising any concerns . Make a list of topics you want to talk about with your child's pediatrician such as development, behavior, sleep, eating or getting along with other family members. Bring your top three to five questions or concerns with you to talk with your pediatrician at the start of the visit.

Team approach . Regular visits create strong, trustworthy relationships among pediatrician, parent and child. The AAP recommends well-child visits as a way for pediatricians and parents to serve the needs of children. This team approach helps develop optimal physical, mental and social health of a child.

More information

Back to School, Back to Doctor

Recommended Immunization Schedules

Milestones Matter: 10 to Watch for by Age 5

Your Child's Checkups

• Bright Futures/AAP Recommendations for Preventive Pediatric Health Care (periodicity schedule)

Coding for Newborn Care Services

Newborn care services coding, care of the normal newborn infant.

Evaluation and management (E/M) services provided to normal newborns in the first days of life prior to hospital discharge are reported with Newborn Care Services codes. Codes for initial care of the normal newborn include:

Newborn Care in the Office

After the newborn has been discharged to home, it is common practice to see the infant to assess for jaundice or any feeding problems. Coding for this service depends on the provider of the service and whether the visit is in follow-up to an already identified problem or screening for problems.

When the visit is in follow-up to an identified problem such as jaundice, infrequent stools, or infrequent feedings, and the physician, nurse practitioner, or physician assistant provides the service, an office visit (e.g., 99212-99215) and problem specific diagnosis codes should be reported.

If no feeding or other health problem has been previously noted, this visit may be the first well-child visit when provided by a physician, nurse practitioner, or physician assistant. Code 99391 may be reported with diagnosis code Z00.129 (encounter for routine child health examination without abnormal findings) for this service. This service includes time spent addressing routine feeding issues.

However, if significant time beyond that typical of the infant preventive service is spent in counseling, physicians may also report a problem-oriented service (99212-99215) with modifier -25 to indicate the significant and separately identifiable services provided on the same date. Documentation should include approximate time spent face-to-face with the family and patient, notation of time spent in counseling, and context of counseling. (Codes may be selected based on time spent in counseling and coordination of care when documentation indicates more than 50% of face-to-face time was spent in these activities.) Diagnosis code Z00.121 (encounter for routine child health examination with abnormal findings) and the appropriate problem diagnosis would be used. If a nurse visit is provided (e.g., weight screen only), code 99211 may be reported. If the nurse visit results in a visit with the physician, only the physician services would be reported. As a family physician, you may also address needs of the mother during a newborn's encounter (e.g., lactation problems). If separately documented in the mother's chart, you may report these services in addition to the services provided to the infant.

Circumcision

Family physicians who perform newborn circumcision should separately report this service. Codes for circumcision procedures include:

Caring for Sick Newborns

When providing E/M services to other than normal newborns, choose the level of care based on the intensity of the service and status of the newborn. Care of newborns who are not normal but do not require intensive services may be reported with codes for initial hospital care (99221-99223). Some infants may require intensive care services but do not meet the CPT definition of critically ill or injured required for reporting of critical care services. (For the definition of critically ill or injured see the Critical Care Services subsection of CPT before codes 99291-99292.) Code 99477 represents initial hospital care of the neonate (28 days or younger) who is not critically ill but requires intensive observation, frequent interventions, and other intensive care services. These services include intensive cardiac and respiratory monitoring, continuous and/or frequent vital sign monitoring, heat maintenance, enteral and/or parenteral nutritional adjustments, laboratory and oxygen monitoring, and constant observation by the health care team under direct physician supervision. This code may be reported only once per day and by only one physician. Procedures included in the services represented by code 99477 include those listed for the Critical Care Services subsection of CPT (codes 99291 and 99292), as well as additional procedures listed in the Inpatient Neonatal and Pediatric Critical Care subsection (codes 99468-99476, 99466-99467). These include vascular access procedures, airway and ventilation management services, oral or nasogastric tube placement, bladder aspiration or catheterization, and lumbar puncture among others.

Subsequent hospital care of infants who are not critically ill or injured as defined in CPT but who had a very low birth weight and continue to require intensive care services as described for code 99477 above may be reported with codes 99478-99480. Codes 99478-99480 each are described as, "Subsequent intensive care, per day, for the evaluation and management of the recovering low or very low birth weight infant" with the code selected based upon the present body weight of the infant as below.

Newborn Critical Care

When the newborn is critically ill or injured, codes exist for reporting of services provided during interfacility transport, initial critical care, and subsequent critical services. Reporting of codes for the services requires careful attention to CPT instructions and when more than one physician is caring for the infant, attention to which physician reports which codes.

Critical Care During Transport

Critical care services delivered by a physician, face-to-face, during an interfacility transport of critically ill or critically injured pediatric patient, 24-months of age or less, are reported based on the time of face-to-face care beginning when the physician assumes primary responsibility at the referring hospital/facility and ending when the receiving hospital/facility accepts responsibility for the patient's care. Report code 99466 for 30-74 minutes of hands-on care and code 99467 for each additional 30 minutes of hands-on care. Less than 30 minutes of hands-on care during transport would not be separately reported.

Inpatient Neonatal Critical Care

The initial day of critical care for the evaluation and management of a critically ill neonate, 28-days of age or less, is reported with code 99468. Only one physician may report this code. If another physician provides critical care services to the neonate on the same date, that physician must report the services with critical care service codes 99291-99292. Subsequent days of critical care to the critically ill neonate are reported per day with code 99469. As with the initial critical care, only one physician may report code 99469 on a given date.

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