EM Coding Alert

Question: Our pediatrician saw an existing 7-week-old patient for a routine checkup with immunizations. During the exam, the physician noticed diaper rash forming. She recommended a couple of over-the-counter creams, advised immediate adminis­tration, and offered additional treatment advice. The doctor then proceeded to administer the vaccines. I understand the vaccine codes, but how would I correctly code the exam and diaper rash? Does this call for modifier 25?

New Hampshire Subscriber

Answer: For the preventive exam, use 99391 (Periodic comprehensive preventive medicine reevaluation and management… infant (age younger than 1 year)). The diaper rash is a separate problem, but the rash does not warrant the use of modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). The infant presented for a routine health exam, and during that exam, the pediatrician discovered the diaper rash. There was no separate evaluation and management (E/M) service associated with a separately identifiable problem that took place independent of the preventive exam.

CPT^® guidelines state, “An insignificant or trivial problem/ abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”

What the pediatrician did here fits this scenario, as no additional workup was needed.

To account for the diaper rash, you need to report Z00.121 (Encounter for routine child health examination with abnormal findings). You’ll also report code L22 (Diaper dermatitis) per the Use additional note associated with Z00.121.