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Medical coding in the United States is complex and uses several coding systems. There are several monographs available that are key to understanding the complexities of CPT coding and reimbursement. The authors suggest that these materials are available to every provider and billing office. These include CPT 2014, Coding for Pediatrics 2014, ICD-9, ICD-10, Coding With Modifiers, CPT Changes 2014, An Insider's View, CPT Assistant (AMA- published monthly), American Academy of Pediatrics Coding Newsletter, Quick Reference Guide to Pediatrics Coding and Documentation, and Quick Reference Guide to Pediatrics Coding and Documentation for Children and Youth with Special Healthcare Needs.

As the incidence of prematurity and neonatal survival has increased, there are now larger numbers of NICU graduates with sequelae (acute, subacute, and chronic), which require involvement of a pediatrician, pediatric subspecialist, developmental pediatrician, or other health care professional. The primary care provider (PCP) must coordinate total care and follow-up services, which may include other specialties such as neurology, cardiology, orthopedics, ophthalmology, surgery, developmental, education, nutrition, occupational therapy, physical therapy, respiratory therapy, social work, and audiology. In addition, community services including regional centers, development programs, and social services are a necessary part of the team.

This chapter will discuss the CPT codes that are most utilized by the primary health care provider working with NICU graduates in the first 2 years of life. In addition, the most common ICD-9/ICD-10 diagnosis codes for follow-up providers and specialists will also be reviewed.

The Evaluation and Management (E/M) Codes

The components are the same for all E/M codes and include the history, physical examination, and medical decision making. There are times when contributory factors such as counseling and coordination of care must be added to the evaluation. Time may be the primary factor used to determine which E/M code to choose when more than 50% of the physician encounter is spent in counseling and/or in coordination of care. A brief description of the components of any E/M codes is discussed below.


The key components of the history include the chief complaint (CC); the history of present illness (HPI); review of systems (ROS); and the past, family, and social history (PFSH).

In addition, there are four levels of historical information: problem focused, expanded problem focused, detailed, and comprehensive.

Physical Examination

There are four levels of physical examination based on the latest 1997 guidelines. These include problem focused, expanded problem focused, detailed problem focused, and comprehensive.

Medical Decision Making

The medical decision making supports the documentation of the history and physical examination. There are three elements of medical decision making: number of diagnoses and/or management options; the amount and/or complexity of data; the risk of morbidity/mortality and other complications. There are four levels of medical ...

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