Documentation of common c onditions in the Newborn Nursery

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

4. BCBS ( Commercial payers) $ Staywell (Medicaid)

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

8. Use the right words to get the right reimbursement

9. Ankyloglossia

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

11. It’s all about the hip

12. 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.

13. 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

14. Size matters LGA / SGA

15. LGA (not associated with IDM) Infants whose weight exceeds the 90th 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

16. SGA (not associated with IDM) Infants whose birthweight is below the 10th 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

17. Hypoglycemia (notassociated with IDM) Definition – blood glucose < 40 mg/dl & treated with GluTose 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

18. < 40 mg/dl

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

20. Affects the Newborn

22. 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

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

24. 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)

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

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

27. 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:

28. Documentation for Syndrome of Infant of a Diabetic Mother 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

29. Infant large for gestation agesecondary to syndrome of infant of a diabetic mother with gestational diabetes 2. Infant small for gestation agedue 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 withsyndrome of infant of a diabetic mother with gestational diabetes Secondary to> due to >>with

30. ABO isoimmunization ABO incompatibility

31. ABO Isoimmunization Mother Blood group O – newborn type A or B Some Group O moms have anti-A, anti-B IgG 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

32. Laboratory testing Coombs Hemoglobin Reticulocyte count Bilirubin Coombs positive

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

34. Prematurity

35. < 37 completed weeks gestation Minimum Documentation Required : Premature / Preterm

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