ICD 10 Coding Alert

Question: If a patient comes in to have our pediatrician review, and then sign off on, an immunization record, and the pediatrician performs no examination, what diagnosis code should I use?

Maryland Subscriber

Answer: In this particular instance, you will have to choose a code from the Z02 (Encounter for administrative examination) group, typically Z02.0 (Encounter for examination for admission to educational institution), Z02.1 (Encounter for pre-employment examination), Z02.3 (Encounter for examination for recruitment to armed forces), or Z02.89 (Encounter for other administrative examinations), which you would use if your patient needed proof of immunization for admission to summer camp or for immigration and naturalization purposes.

And don’t forget: If your pediatrician documents spending at least 10 minutes with the patient, and spending six or more minutes of that time counseling the patient on the need for updating vaccines, you could bill 99212 (Office or other outpatient visit for the evaluation and management of an established patient ... Typically, 10 minutes are spent face-to-face with the patient and/or family).