Documentation of common conditions in the Newborn Nursery

Documentation of common conditions in the Newborn Nursery J. Douglas Campbell MD Physician Advisor Clinical Documentation Integrity Wolfson Children’s Hospital

BCBS ( Commercial payers) Staywell (Medicaid)

If you do the work… Why not get paid for what you do?

Use the right words to get the right reimbursement

Ankyloglossia

Ankyloglossia Single live newborn with ankyloglossia ROM – 1 SOI - 1 BCBS - improved reimbursement Medicaid (Staywell) no change Minimum Documentation Required: 1. Lactation nurse to assess feeding secondary to anklyoglossia 2. Follow up ankyloglossia with pediatrician / ENT

Single live newborn with congenital hip dysplasia ROM – 1 SOI - 1 BCBS - improved reimbursement Medicaid (Staywell) – no change Minimum Documentation Required - Presumed (suspected/probable/likely) developmental dysplasia of the hip (DDH) will require follow-up hip ultrasound.

Single live newborn with Breech presentation ROM – 2 SOI - 1 BCBS –$ improved reimbursement Medicaid (Staywell) $improved Minimum Documentation Required: Breech presentation – will require follow-up ultrasound

Size matters

LGA (not associated with IDM) Infants whose weight exceeds the 90 th percentile for gestational age are classified as LGA Single live newborn with LGA ROM – 1 SOI - 1 BCBS – no change Medicaid (Staywell) – no change Minimum Documentation Required: Infant is LGA

SGA (not associated with IDM) Infants whose birthweight is below the 10 th percentile, when plotted against gestational age on a standard growth curve, are considered small for gestational age (SGA) Single live newborn with SGA ROM – 2 SOI - 1 BCBS – improved reimbursement Medicaid (Staywell) – improved Minimum Documentation Required: Infant is SGA

Hypoglycemia (not associated with IDM) Definition – blood glucose < 40 mg/dl & treated with Glu. Tose gel or IV glucose NOT treated with only formula or breast feeding Single live newborn with Hypoglycemia ROM – 2 SOI - 1 BCBS – improved reimbursement Medicaid (Staywell) - improved

And the word HYPOGLYCEMIA Not - Low blood sugar Not - Low serum glucose Minimum Documentation Required: Hypoglycemia

NEONATAL EFFECTS — IDMs are at increased risk for mortality and morbidity compared with neonates born to a nondiabetic mother Neonatal complications in infant’s of diabetic mothers include: ●Congenital anomalies – 5% ●Prematurity – 36% ●Microsomia – see in 20% of IDM vs. 10% in non-IDM ●Macrosomia, which increases the risk of birth injury (eg, brachial plexus injury) – 34% ●Respiratory distress – 33% ●Metabolic complications including hypoglycemia and hypocalcemia ●Hematologic complications including polycythemia and hyperviscosity ●Hyperbilirubinemia – 25% ●Cardiomyopathy

Despite the propensity for abnormalities associated with maternal diabetes, many IDM’s are born without any complications or abnormalities

Infant of Diabetic Mother No complications / associated entities Single live newborn that is “Infant of diabetic mother” ROM - 1 SOI - 1 BCBS - no change Medicaid (Staywell) – no change Minimal Documentation Required : Infant of diabetic mother with gestational / Non-gestational diabetes (Type I or Type II)

When there is a condition associated with the maternal diabetes…………

Syndrome of Infant of a Diabetic Mother IDM with a condition which felt to be secondary to (or associated with) maternal diabetes. 1. 2. 3. 4. 5. LGA / SGA Hypoglycemia Hyperbilirubinemia Polycythemia Transient tachypnea of newborn

Syndrome of infant of diabetic mother Single live newborn with “Syndrome of infant of diabetic mother” ROM - 2 SOI - 1 BCBS – improved reimbursement Medicaid (Staywell) - improved Let’s l k at documentation:

Documentation for Syndrome of Infant of a Diabetic Mother 1. Document the maternal diabetes as: a. gestational b. non-gestational (Type I or II) 2. The entity felt to be associated with maternal diabetes 3. Linkage utilizing the words: secondary, due to or with 4. Use the words syndrome of IDM

1. Infant large for gestation age secondary to syndrome of infant of a diabetic mother with gestational diabetes 2. Infant small for gestation age due to syndrome of infant of a diabetic mother with Type I diabetes 3. Infant with hypoglycemia secondary to syndrome of infant of a diabetic mother with Type II diabetes 4. Infant with polycythemia with syndrome of infant of a diabetic mother with gestational diabetes Secondary to > due to >> with

ABO isoimmunization ABO incompatibility

ABO Isoimmunization Mother Blood group O – newborn type A or B Some Group O moms have anti-A, anti-B Ig. G antibodies Can result in hemolysis in fetus/newborn More common and more severe in African Americans Can occur with first pregnancy Less severe than Rh incompatibility 55/1000 live births

Laboratory testing 1. Coombs 2. Hemoglobin 3. Reticulocyte count 4. Bilirubin Coombs positive

ABO Isoimmunization Single live newborn ROM – 1 SOI – 1 BCBS - $ X Medicaid (Staywell) - $ Y Single live newborn with ABO iso-immunization ROM – 2 SOI - 1 BCBS – improved reimbursement Medicaid (Staywell) - improved Minimum Documentation Required: ABO isoimmunization

Prematurity

< 37 completed weeks gestation Minimum Documentation Required : Premature / Preterm

Why leave it on the tree? Why leave it on the table?