Alicia:  OK. She’s got another slide; lots of knowledge tonight from JoAnne. New Baby Office Visit, we get a lot of questions about this so I’m glad that JoAnne did this particular presentation.

JoAnne:  Q:  How do I bill and get paid for new baby visits in the Family Practice?  I have more denials than payments.

A:  This is going to be approached from a billing and coding perspective. I have talked before in just regular billing where you can bill a preventive along with a sick visit at the same time adding a modifier-25 to, say, 99212 that requires a medical necessity.

New Baby Medical Coding for Office Visits – Video

Talking about a newborn, after a newborn is discharged home, he will begin to see his physician in the office, depending on whether or not the pediatrician saw the baby in the hospital, it depends on whether you use a 99381 as the Initial Comprehensive Preventive Visit (under age one), or if the doctor did see the baby in the hospital you would be billing a 99391. That’s very important.

If the newborn is identified as having something as jaundice or low birth weight, that is considered a medical necessary visit and you would add an E/M code with that. Like I said, same concept as if you were billing for an adult visit, you can’t combine a wellness and a sick visit. That part is the easy part, it’s the billing end of it that is really a pain in the neck.

First of all, parents have to enroll their babies in the family insurance plan under a separate ID number. They must stress to the patient when they call the office with their first appointment. I’ll explain why; newborn coverage varies by carrier and billing is easier if the office already has the ID number.

I’m going to point out four examples of why it makes it easier to have the number. Number one, these are valid newborn coverage. If the newborn has not been added to the plan within 60 days, the payer will reimburse all routine newborn care under the mother. That’s one rule.   The next insurance company, the payer will reimburse the physician under the mother for routine and non-routine care but only up to 31 days. Another payer will reimburse under the mother’s ID number up to the first 61 days of a newborn’s life. The last one: All incurred inpatient well newborn services are included in the mother’s obstetrical stay. If the newborn is not added as a dependent upon the mother’s discharge from the hospital, coverage of well newborn care will cease.

Why there’s a problem, you want to first communicate again to the parents to enroll as quickly as possible. You need to know the rules of the insurance carrier. The reason why it makes it easier to get the ID number ahead of time is because if you’re allowed to bill under the mother’s name and date of birth, the computer is automatically going to kick it out because a newborn code does not correlate with the mom that was born in 1983.

And the one thing I hate in billing is fixing denied claims. I’m just saying it can be ten minutes to an hour to fix this claim, so even though the rules say, “Oh, we’ll pay under mom,” you have to do the work to get it paid.

The last thing is, if a mom and dad leaves and says, “Oh, I’ll call you with the ID number,” don’t put the encounter form aside. Bill it, even if you know it’s going to get denied. The reason is, is that insurance companies, they have 60 days, 90 days, a year to bill. You push that aside and if the mom decides to call on the 93rd day, you can’t appeal that claim, it’s not in the insurance database. So, just get it in there, because you have 90 days to bill, let’s assume it denies; then, you have another 90 days from the denial date. So, it’s a lot of work, so I think the front desk should be proactive to get the information as soon as possible and avoid the whole appeal process. Anyway, that’s just my opinion. I can’t stand it when I have denial appeal.

Alicia:  And mommies and daddies are not thinking about insurance after that baby is born. That’s the last thing they’re thinking about, they may be all excited about the first doctor visit, but their insurance is not on their mind.

Boyd:   I would disagree. I think after the first one; if it’s your second, you very much pay attention to that.

Alicia:  There you go. Yeah, you’re right, Boyd.

Learn More Details About New Baby Medical Coding

OB Medical Coding: Mother and Baby — Video

AAPC – Newborn Coding

new baby medical coding


About the Author:

Alicia has been working in the medical field for over 20 years. She first learned about medical coding while working in a medical records department at a resort town hospital near where she was raised. Through the years she has held several jobs in the medical field from, CNA, EMT, Pharmacy technician and Medial Records Abstractor and Analyst. Outside of the medical field she has worked as a Real Estate agent, and owned her own on-line retail business. The medical field has always been where she felt the most comfortable. Alicia has taught medical coding, billing and medical law and ethics at a private college. She also did contract work in HCC Risk Adjustment and discovered she really enjoyed ICD work. Because she loves to learn Alicia is working towards her Masters in Health Care Administration with an emphasis on education. Having taken many online classes through the years to complete her degree she feels very comfortable with both face to face and on-line learning. Alicia will tell you that not only does she love medical coding but she has a passion for teaching it. Alicia lives in the middle of Texas with her husband who is a Pastor, five of her six children, three dogs and two cats.


  1. Amaal May 29, 2016 at 1:07 am - Reply

    This amazing information , thank you

  2. Alicia Scott
    Alicia Scott May 31, 2016 at 9:38 am - Reply

    I am glad it was helpful.

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