Streamlining Newborn Billing: Key Considerations for Healthcare Practices

Billing for newborn office visits can be a complex process for healthcare practices, particularly when navigating the intricate rules of insurance carriers. Understanding the nuances of newborn billing, from initial coding to ensuring proper insurance enrollment, is crucial for minimizing denials and ensuring timely reimbursements.

Coding for Newborn Office Visits

When a newborn is discharged from the hospital, the type of visit billed depends on whether the pediatrician saw the baby in the hospital. If the pediatrician did not see the newborn at the hospital, the initial comprehensive visit should be billed under code 99381 (for patients under the age of one). Conversely, if the pediatrician did see the baby in the hospital, the appropriate code would be 99391.

If the newborn presents with a condition such as jaundice or low birth weight, this constitutes a medically necessary visit. In such cases, an Evaluation and Management (E&M) code should be added, similar to billing for an adult visit, where a wellness and sick visit can be combined using modifier 25.

The Importance of Timely Insurance Enrollment

A critical step in the billing process is ensuring that parents enroll their newborns in a family insurance plan as soon as possible. Newborn coverage varies significantly between insurance carriers, and having the baby’s insurance ID number at the time of the first appointment can simplify the billing process and prevent denials.

Examples of Insurance Carrier Rules:

• 60-Day Enrollment Rule: Some insurance carriers require the newborn to be added to the plan within 60 days. If not, the carrier may only reimburse routine preventive newborn care.
• 31-Day Coverage Rule: Another carrier may cover routine and non-routine care under the mother’s ID for up to 31 days.
• 61-Day Coverage Rule: A different payer may extend coverage under the mother’s ID for up to 61 days.
• Inpatient Coverage: Some carriers include all inpatient well newborn services in the mother’s obstetrical stay. However, if the newborn is not enrolled as a dependent upon the mother’s discharge, coverage for well newborn care will cease.

Proactive Communication with Parents

Given the variations in insurance coverage, it is essential for the front desk staff to communicate the importance of enrolling the newborn in the family insurance plan promptly. Encouraging parents to provide the newborn’s insurance ID number before the first appointment can prevent time-consuming claim denials.

Managing Claim Denials

If the office has to bill under the mother’s name and date of birth due to delays in obtaining the newborn’s insurance information, the claim may be automatically denied. This happens because newborn codes do not align with the mother’s date of birth, leading to mismatches in the billing system.

To avoid lengthy delays, it is advisable to submit the claim as soon as possible, even if the office expects it to be denied. Once the claim is denied, practices have additional time (usually another 90 days) to resolve the denial, provided the claim was initially submitted within the payer’s timeframe.

Conclusion

Newborn billing requires attention to detail, timely insurance enrollment, and proactive communication with parents. By understanding the specific rules of each insurance carrier and ensuring that claims are submitted promptly, healthcare practices can reduce denials and streamline the billing process.

For more information on how Svast Healthcare Technologies can assist with pediatric medical billing, click here.