CPT Code 99460: Initial Hospital or Birthing Center Care Per Day

Better understand how to use CPT code 99460 with our guide, complete with information on documentation and billing requirements.

Use Code

What is the 99460 CPT code?

CPT code 99460, defined as "Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant," is reported for initial evaluation and management of a normal newborn infant admitted and discharged on the same day, by a physician or qualified provider.

The code includes normal newborn care services such as a comprehensive medical history review, a physical examination, ordering of tests and treatments (if necessary), anticipatory guidance, and meetings with he family, and documentation of findings in the hospital medical record.

Do note that this code is not for critical care services or other intensive care services provided to a normal newborn infant, nor is it for a critically ill neonate, or newborns with congenital anomalies, pre

This code is limited to healthy newborns without congenital anomalies, prematurity-related complications, or need for intensive care.

CPT code 99460 documentation requirements

Documentation must include:

Time, date, and location of the initial service
Birth details (APGAR scores, gestational age, delivery method)
Comprehensive physical examination and newborn vitals
Feeding status, weight, and parental bonding observations
Plan for routine newborn care (e.g., hearing screen, hepatitis B vaccine)
Counseling or education provided to parents

Include any interventions or referrals for further care if needed.

CPT code 99460 billing guidelines

Report once per newborn per hospital admission for the initial care.
Use 99462 for subsequent days of normal newborn care.
If care is provided in a location other than the hospital (e.g., birthing center), use 99461.
Do not use 99460 for ill or premature newborns—see NICU codes like 99468.
Some newborns may need intensive services and it's essential to use appropriate codes for these.

This service is typically billed by the delivering pediatrician or hospital-based provider.