Claim Denials due to Inaccurate Newborn Billing Guidelines

Aetna Better Health along with other commercial payers receives a lot of inaccurate claims submitted due to inaccurate newborn billing. Most of the claims are of procedure code 99479 billed by neonatologist/pediatric groups whose patients are no longer of newborn age but are still billing with newborn diagnosis codes. Per CMS Policy a newborn is defined as the first 28 days of life. As per the ICD-10-CM manual, if the condition first presents after 28 days, it is not considered a newborn condition.

The newborn codes may be used throughout the life of the patient, if the condition was noted as present during the first 28 days of life, and if the condition remains present after 28 days. It is inappropriate to bill procedures using an ICD-10 code that is specific to newborns when the patient is not of newborn age. When you are accurately billing for newborn care services, you receive quicker payments lesser claim denials, resulting in improved cashflow.

Newborn Billing Guidelines

As mentioned above the newborn period is defined as beginning at birth and lasting through the 28th day following birth. The following guidelines are provided for reporting purposes. Hospitals may record other diagnoses as needed for internal data use. All clinically significant conditions noted on routine newborn examination should be coded. A condition is clinically significant if it requires:

  • clinical evaluation; or
  • therapeutic treatment; or
  • diagnostic procedures; or
  • extended length of hospital stay; or
  • increased nursing care and/or monitoring; or
  • has implications for future health care needs.

Note that the newborn guidelines listed above are the same as the general coding guidelines for ‘other diagnoses,’ except for the final bullet regarding implications for future health care needs. Whether or not a condition is clinically significant can only be determined by the physician.

Normal Newborn Care

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 99460 and 99462 codes.

  • 99460: Initial hospital or birthing center care, per day, for E/M of the normal newborn infants.
  • 99461: Initial care per day, for E/M of normal newborn infant seen in other than hospital or birthing center.
  • 99462: Subsequent hospital care, per day, for E/M of normal newborn codes.

Sick Newborn Care

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

All the above codes should be reported based on meeting or exceeding the required key elements or based on time per the CPT code descriptors.

Use of Codes V30-V 39

When coding the birth of an infant, assign a code from categories V30-V39, according to the type of birth. A code from this series is assigned as a principal diagnosis and assigned only once to a newborn at the time of birth. Note that if the newborn is transferred to another institution, the V30 series is not used.

Use of Category V29

Assign a code from category V29, Observation and evaluation of newborns and infants for suspected conditions not found, to identify those instances when a healthy newborn is evaluated for a suspected condition that is determined after study not to be present. Do not use a code from category V29 when the patient has identified signs or symptoms of a suspected problem; in such cases, code the sign or symptom. A V29 code is to be used as a secondary code after the V30, Outcome of delivery, code. It may also be assigned as a principal code for readmissions or encounters when the V30 code no longer applies. It is for use only for healthy newborns and infants for which no condition after study is found to be present.

Maternal Causes of Perinatal Morbidity

Codes from categories 760-763, Maternal causes of perinatal morbidity and mortality, are assigned only when the maternal condition has actually affected the fetus or newborn. The fact that the mother has an associated medical condition or experiences some complication of pregnancy, labor, or delivery does not justify the routine assignment of codes from these categories to the newborn record.

Congenital Anomalies

Assign an appropriate code from categories 740-759, Congenital anomalies, when a specific abnormality is diagnosed for an infant. Such abnormalities may occur as a set of symptoms or multiple malformations. A code should be assigned for each presenting manifestation of the syndrome if the syndrome is not specifically indexed in ICD-10-CM.

Coding of Other (Additional) Diagnoses:

  • Assign codes for conditions that require treatment or further investigation, prolong the length of stay, or require resource utilization.
  • Assign codes for conditions that have been specified by the physician as having implications for future health care needs.
  • Assign a code for Newborn conditions originating in the perinatal period (categorie760-779), as well as complications arising during the current episode of care classified in other chapters, only if the diagnoses have been documented by the responsible physician at the time of transfer or discharge as having affected the fetus or newborn.
  • Insignificant conditions or signs or symptoms that resolve without treatment are not coded.

Prematurity and Fetal Growth Retardation

Codes from categories 764 and 765 should not be assigned based solely on recorded birth weight or estimated gestational age but upon the attending physician's clinical assessment of the maturity of the infant.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. We referred various billing documents to share newborn billing guidelines in detail. You can also refer following links for a detailed understanding. These newborn billing guidelines will assist you in billing accurately for commercial and government payers. In case of any assistance needed for neonatologist / pediatric billing, email us at: or call us: 888-357-3226.

CPT Code: Copyright 2022 American Medical Association


ICD-10: Clinical Concepts for Pediatrics

FY2022 April 1 update ICD-10-CM Guidelines

Published By - Medical Billers and Coders
Published Date - Sep-27-2022 Back

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