Newborn babies will have had a complete exam at birth and at discharge from hospital. The discharge exam fee counts as a complete exam; therefore, a complete exam (12101) is not usually billable until 6 months of age at the earliest. An exception would be if the newborn care was provided by a midwife and not a physician. Only the office visit (12100) is billable when you see a newborn in your office for a growth, development and milestone exam in the first 6 months after birth.

A complete exam (12101) for growth, development and milestone assessment is billable at 6, 12 and 18 months, if the fee code criteria is fulfilled. Document your findings, including growth charts and Rourke Baby Record. For other visits, only the office visit (12100) is billable, even if you are essentially doing a full physical exam.

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