Hyperbilirubinemia – 4-day-old
Medical Specialty: Emergency Room Reports
Description: 4-day-old with hyperbilirubinemia and heart murmur
HISTORY: The patient is a 4-day-old being transferred here because of hyperbilirubinemia and some hypoxia. Mother states that she took the child to the clinic this morning since the child looked yellow and was noted to have a bilirubin of 23 mg%. The patient was then sent to Hospital where she had some labs drawn and was noted to be hypoxic, but her oxygen came up with minimal supplemental oxygen. She was also noted to have periodic breathing. The patient is breast and bottle-fed and has been feeding well. There has been no diarrhea or vomiting. Voiding well. Bowels have been regular.
According to the report from referring facility, because the patient had periodic breathing and was hypoxic, it was thought the patient was septic and she was given a dose of IM ampicillin.
The patient was born at 37 weeks’ gestation to gravida 3, para 3 female by repeat C-section. Birth weight was 8 pounds 6 ounces and the mother’s antenatal other than was normal except for placenta previa. The patient’s mother apparently went into labor and then underwent a cesarean section.
FAMILY HISTORY: Positive for asthma and diabetes and there is no exposure to second-hand smoke.
PHYSICAL EXAMINATION:
VITAL SIGNS: The patient has a temperature of 36.8 rectally, pulse of 148 per minute, respirations 50 per minute, oxygen saturation is 96 on room air, but did go down to 90 and the patient was given 1 liter by nasal cannula.
GENERAL: The patient is icteric, well hydrated. Does have periodic breathing. Color is pink and also icterus is noted, scleral and skin.
HEENT: Normal.
NECK: Supple.
CHEST: Clear.
HEART: Regular with a soft 3/6 murmur. Femorals are well palpable. Cap refill is immediate
ABDOMEN: Soft, small, umbilical hernia is noted, which is reducible.
EXTERNAL GENITALIA: Those of a female child.
SKIN: Color icteric. Nonspecific rash on the body, which is sparse. The patient does have a cephalhematoma hematoma about 6 cm over the left occipitoparietal area.
EXTREMITIES: The patient moves all extremities well. Has a normal tone and a good suck.
EMERGENCY DEPARTMENT COURSE: It was indicated to the parents that I would be repeating labs and also catheterize urine specimen. Parents were made aware of the fact that child did have a murmur. I spoke to Dr. X, who suggested doing an EKG, which was normal and since the patient will be admitted for hyperbilirubinemia, an echo could be done in the morning. The case was discussed with Dr. Y and he will be admitting this child for hyperbilirubinemia.
CBC done showed a white count of 15,700, hemoglobin 18 gm%, hematocrit 50.6%, platelets 245,000, 10 bands, 44 segs, 34 lymphs, and 8 monos. Chemistries done showed sodium of 142 mEq/L, potassium 4.5 mEq/L, chloride 104 mEq/L, CO2 28 mmol/L, glucose 75 mg%, BUN 8 mg%, creatinine 0.7 mg%, and calcium 8.0 mg%. Total bilirubin was 25.4 mg, all of which was unconjugated. CRP was 0.3 mg%. Blood culture was drawn. Catheterized urine specimen was normal. Parents were kept abreast of what was going on all the time and the need for admission. Phototherapy was instituted in the ER almost after the baby got to the emergency room.
IMPRESSION: Hyperbilirubinemia and heart murmur.
DIFFERENTIAL DIAGNOSES: Considered breast milk, jaundice, ABO incompatibility, galactosemia, and ventricular septal defect.
Medical Coding “Clarified” — How to Code a Newborn with Hyperbilirubinemia (ER Visit)
Understanding how to code neonatal emergency cases is critical for CPC exam success and real-world coding accuracy. This case walks you through a 4-day-old newborn presenting with hyperbilirubinemia, hypoxia, and a heart murmur, using a step-by-step coding process.
Start with the Chief Reason for the Visit
The primary reason for this encounter is clearly:
- Hyperbilirubinemia (elevated bilirubin levels)
- Visible jaundice (icterus)
- Lab confirmation: bilirubin 25.4 mg
ICD-10-CM Code
- P59.9 — Neonatal jaundice, unspecified
Rationale
This is a newborn condition, so coding begins in Chapter 16 (Perinatal Conditions).
Although possible causes (breast milk jaundice, ABO incompatibility) are mentioned, they are not confirmed, so we code only the documented condition.
Capture Additional Reportable Conditions
Heart Murmur
- Documented as: “soft 3/6 murmur”
Code:
- R01.1 — Cardiac murmur, unspecified
Rationale:
The murmur is clinically evaluated and impacts medical decision-making (EKG ordered, echo planned).
Respiratory Abnormalities (Hypoxia & Periodic Breathing)
- “noted to be hypoxic”
- “periodic breathing”
Code:
- P28.89 — Other specified respiratory conditions of newborn
Rationale:
Because this is a newborn, we must use a perinatal (P-code) rather than adult respiratory codes. These findings required monitoring and oxygen support.
Cephalhematoma
- “cephalhematoma about 6 cm”
Code:
- P12.0 — Cephalhematoma due to birth injury
Rationale:
This is a birth-related injury, not just a general hematoma, so it must be coded from the perinatal section.
Assign the Correct CPT (Procedure) Codes
Emergency Department Visit
This encounter supports a high-level ED visit.
Code:
- 99285 — Emergency department visit, high complexity
Rationale
This case meets high complexity due to:
- Newborn (high-risk patient)
- Severe hyperbilirubinemia (>25 mg)
- Hypoxia and concern for possible sepsis
- Multiple diagnostics performed:
- Labs
- Blood culture
- EKG
- Decision to admit
This reflects high medical decision-making (MDM).
Electrocardiogram (EKG)
- “EKG… normal”
Code:
- 93005 — Electrocardiogram, tracing only
Rationale:
The ED physician ordered and performed the tracing. Interpretation may be billed separately depending on documentation.
Venipuncture
- Labs obtained (CBC, chemistries, bilirubin, CRP)
Code:
- 36415 — Routine venipuncture
Rationale:
Represents the blood draw performed during the visit. Individual lab tests are typically billed by the facility.
HCPCS Considerations
- No HCPCS codes assigned
Rationale
Phototherapy was initiated, but:
- In the hospital setting, phototherapy is typically billed by the facility, not separately by the physician.
What NOT to Code (Critical CPC Exam Strategy)
This is where many students lose points.
Do NOT code:
- Sepsis → only suspected, not confirmed
- ABO incompatibility → listed as differential only
- Breast milk jaundice → not diagnosed
- Ventricular septal defect → not confirmed
- Umbilical hernia → incidental, not treated
Key Rule
Only code confirmed diagnoses, not:
- Differentials
- Rule-outs
- Suspected conditions (outpatient setting)
Final Code Summary
ICD-10-CM
- P59.9 — Neonatal jaundice
- R01.1 — Cardiac murmur
- P28.89 — Respiratory condition of newborn
- P12.0 — Cephalhematoma
CPT
- 99285 — ED visit, high complexity
- 93005 — EKG tracing
- 36415 — Venipuncture
HCPCS
- None
CPC Exam Tips from This Case
- Always start with the reason for the encounter
- Use P-codes for newborns whenever applicable
- Do not code unconfirmed conditions
- ED levels are based on:
- Risk
- Data reviewed
- Complexity of decision-making
- Watch for facility vs. physician billing differences
Coding Clarified Final Takeaway
This case is a great example of how one chief complaint (jaundice) can expand into multiple reportable conditions when you carefully review the documentation.
A strong coder:
- Reads the full chart
- Identifies confirmed conditions
- Applies correct coding hierarchy
- Avoids over coding
American Academy of Allergy, Asthma, and Immunology