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36.4.25.10 Routine Care
Routine newborn care during the initial hospital/birthing center stay is defined as care given to a newborn immediately after birth. Services should be submitted using procedure codes 1-99431, 1-99433, and 1-99435.
Physicians must submit separate charges for each day of care. Procedure codes 1-99431, 1-99432, 1-99433, and 1-99435 are limited to one code per day, per provider. The claim must not reflect any diagnosis other than well newborn diagnosis listed in the table below:
Initial newborn care (procedure codes 1-99431 and 1-99435) are considered for reimbursement once per lifetime, any provider, when provided in the hospital.
Initial newborn care (procedure codes 1-99432 and 1-99435) are considered for reimbursement once per lifetime, any provider when provided in a birthing center.
Normal newborn care (procedure code 1-99432) provided in other than the hospital or birthing room setting may be considered for reimbursement once per lifetime, any provider. Subsequent visits should be submitted using an appropriate visit procedure code based on the POS (i.e., office visit or subsequent hospital care if the infant is admitted to the hospital).
Procedure code 1-99435 may be considered for reimbursement when newborns are admitted and discharged on the same day from the hospital or birthing center. If procedure codes 1-99431 and 1-99435 are submitted with the same date of service, procedure code 1-99431 is denied and procedure 1-99435 is considered for reimbursement.
If the patient is re-admitted within the first 30 days of life, the provider should submit an initial admit code.
Subsequent hospital care (procedure code 1-99433) is considered for reimbursement once per day in the hospital. Procedure code 1-99433 is not considered for reimbursement in the birthing center. If procedure code 1-99431 is submitted with the same date of service as 1-99433, procedure code 1-99433 is denied and procedure code 1-99431 is considered for reimbursement.
For a single visit for complete normal newborn services regardless of place of birth, use procedure 1-99435.
If procedure code 1-99436 is submitted with the same date of service as an outpatient E/M procedure code (1-99201, 1-99202, 1-99203, 1-99204,1-99205, 1-99211, 1-99212, 1-99213, 1-99214, or 1-99215), the outpatient E/M service is denied. Payment may be considered on appeal with supporting documentation.
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