What CPT codes are used for outpatient newborn visits?

Outpatient newborn visits use E/M codes: 99202-99205 for new patients, 99381/99391 for preventive visits based on age. The first outpatient visit after hospital discharge is typically billed as new patient (99202-99205) based on complexity. Subsequent well-baby visits use preventive codes. For weight checks only, use 99211 or appropriate E/M level.

What weight monitoring documentation is required for newborns?

Document: birth weight, discharge weight, current weight, percentage change from birth weight, and trajectory. Normal weight loss is 10% requires intervention. Document feeding adequacy (wet diapers, stools, feeding frequency) and plan if weight gain inadequate. Weight regain to birth weight by 10-14 days expected.

How should feeding assessment be documented?

Document: feeding method (breast, formula, combination), frequency and duration, latch quality if breastfeeding, mother's milk supply, supplementation if used, and wet/dirty diaper counts. For breastfeeding problems, document lactation consultation referral. Include feeding-related concerns (jaundice risk, dehydration signs) and interventions recommended.

What newborn screening documentation is required?

Document: state newborn screen collection date, results if available, and follow-up for abnormal results. Document hearing screen result (pass, refer, not done) with plan for failed screens. Document CCHD screen if applicable. Track any pending results and document plan for follow-up. Inadequate screens require repeat testing.

What anticipatory guidance documentation is needed for newborn visits?

Document: safe sleep counseling (back to sleep, firm surface, room sharing), feeding guidance (frequency, hunger cues, adequate intake signs), umbilical cord care, temperature monitoring, car seat safety, when to call provider (fever >100.4°F rectal, poor feeding, lethargy, jaundice), and appointment scheduling. Demonstrates comprehensive newborn care education.

Newborn Visit Template - First Pediatric Exam

Primary Care — Newborn Visit Template

Primary Care Pediatrics Updated: 11/7/2025

The Newborn Visit Template is designed for pediatricians and family medicine providers conducting the initial newborn examination and establishing care for infants. This comprehensive template documents the complete newborn evaluation including birth history, feeding assessment, physical examination, developmental assessment, screening test results, and anticipatory guidance. The template supports appropriate billing for newborn visits (CPT 99460-99462) and includes sections for birth history including delivery type and complications, feeding history including breastfeeding or formula feeding status, elimination patterns, physical examination including comprehensive newborn assessment, weight and growth parameters, screening test results including newborn screen and hearing screen, assessment of newborn health and development, anticipatory guidance for parents, and follow-up scheduling. This template ensures thorough newborn care, identifies health concerns early, supports parent education, and establishes foundation for ongoing pediatric care. Ideal for pediatric practices, family medicine practices providing pediatric care, and practices managing newborns in the first weeks of life.

Visit Information

Infant name, DOB, age: [X] days
Birth weight: [Weight] grams/lbs
Current weight: [Weight] grams/lbs
Weight change: [Gain/loss since birth]

Birth History

Delivery type: Vaginal / Cesarean
Gestational age: [X] weeks
Birth complications: None / [Specify]
APGAR scores: [1 min / 5 min]
NICU stay: Yes / No (if yes, reason and duration)
Discharge date: [Date]

Feeding History

Feeding method: Breastfeeding / Formula / Both
Feeding frequency: [Times per day]
Feeding duration: [Minutes per feed]
Feeding concerns: None / [Specify]
Jaundice: None / Present (treatment: [specify])

Elimination

Urine output: [Wet diapers per day]
Stool output: [Stools per day]
Stool characteristics: [Color, consistency]

Physical Examination

Vital signs: HR, RR, Temp, SpO2
General: Appearance, activity, tone
Head: Fontanelles, sutures, shape, caput/molding
Eyes: Red reflex, discharge, alignment
Ears: Position, external exam
Nose: Patency, discharge
Mouth: Palate, tongue, suck
Neck: Masses, range of motion
Cardiovascular: Heart rate, rhythm, murmurs, pulses, perfusion
Respiratory: Rate, effort, breath sounds
Abdomen: Soft, non-distended, bowel sounds, organomegaly
Genitalia: [Normal / Abnormal findings]
Hips: [Barlow/Ortolani if indicated]
Extremities: [Symmetry, range of motion]
Neurological: Tone, reflexes, Moro, grasp, rooting
Skin: [Color, rashes, birthmarks]

Screening Tests

Newborn screen: Collected / Pending / Results: [if available]
Hearing screen: Passed / Referred / Pending
Bilirubin: [Level if checked]

Assessment

1) Newborn, [X] days old

Feeding: Going well / Concerns: [specify]
Growth: Appropriate / Concerns: [specify]
Physical exam: Normal / Abnormal findings: [specify]

2) [Other diagnoses as applicable]

Plan

1) Continue current feeding plan / Adjustments: [specify]
2) Follow weight: [Next weight check]
3) Screening: [Newborn screen, hearing, etc.]
4) Anticipatory guidance: [Feeding, sleep, safety, development]
5) Follow-up: Return in [timeframe] for [type of visit]

Parent Education

Feeding guidance, sleep safety, car seat safety, when to call, warning signs.