From the health record of a newborn delivered in a birthing room setting: This infant was born at 10:58 a.m. on September 1. He weighed 8 lb, 5 oz and was 21 inches long with Apgar scores of 9 and 9. Dr. Smith performed a history and examination immediately following the vaginal delivery with no abnormal findings. Parents declined circumcision and administration of hepatitis B vaccine. The patient was discharged at 6:30 p.m. with his mother. Which CPT code(s) is appropriate for Dr. Smith’s services on September 1?
In this scenario, Dr. Smith provided services related to the newborn immediately following delivery in a birthing room setting. These services typically involve the initial assessment and examination of the newborn. The appropriate CPT code(s) for Dr. Smith’s services on September 1 can be determined as follows:
99460 – Initial hospital care, per day, for the evaluation and management of a normal newborn infant (age 28 days or less) who is discharged on the same date of service (billed once per day).
This code is used for the initial evaluation and care of a normal newborn, including the examination and assessment following delivery.
99238 – Hospital discharge day management; 30 minutes or less.
This code may be used for the discharge management services provided to the newborn and mother on the same day of discharge, which was September 1 in this case.
Based on the information provided, the appropriate CPT code(s) for Dr. Smith’s services on September 1 would be:
99460: For the initial evaluation and management of the newborn.
99238: For the hospital discharge day management services.
Therefore, option (a) “99460, 99238” is the most suitable choice for Dr. Smith’s services in this scenario.
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