Pediatric Coding Alert

According to CPT, a physician may bill a sick visit (office or other outpatient services codes 99212-99215) in addition to a previously scheduled preventive medicine service (99381-99385 and 99391-99395) if the presenting problem is significant enough to require additional work to perform the key components of a problem-oriented E/M [evaluation and management] service and modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached.

As with any E/M service, the severity of the diagnosis, intensity of medical decision-making and time spent on counseling and coordination of care determine correct coding. Because differentiating the office visit exam from the preventive medicine services visit exam can be problematic, documentation must rest with the history of the present illness and the medical decision-making connected with that illness.

Note: For more information on choosing correct E/M levels, see Pediatric Coding Alert, January 2001, pages 1-5.

Learn by Example

The following examples, common in pediatric practice, illustrate situations in which coding for an office visit at the same time as a preventive medicine service would be justified:

Asthma: This common, chronic condition could justify an office visit at every well visit, says Richard H. Tuck, MD, FAAP, a member of the coding and reimbursement committee of the American Academy of Pediatrics (AAP). The physician must take a history of the asthma, review the medications, perhaps adjust the medication, review monitoring of peak flows and environmental issues, he reasons. When coding the visit, link the asthma diagnosis code (493.00, extrinsic asthma, without mention of status asthmaticus or 493.02 , extrinsic asthma, with acute exacerbation) to the sick visit.

Charles Scott, MD, FAAP, a pediatric coding expert who practices with Medford Pediatric & Adolescent Medicine in Medford, N.J., warns, however, that to bill for an office visit in addition to a well visit for asthma, the pediatrician must perform and document a significant examination. If youre simply asking, How are things going? Are you OK with your medication? thats not enough, he explains.

Migraine headaches: A recurrent headache problem often surfaces during a well visit. In this case the pediatrician must review headache management, prescribe analgesics and determine a differential diagnosis. If properly documented, this justifies coding a separate E/M service. Proper documentation for an established patient office visit requires two of the three elements of exam, history and medical decision-making. When providing preventive medicine services, the examination is very thorough, and medical decision-making is easy to document with migraine headaches there is risk and multiple possible diagnoses. Link the migraine diagnoses (346.xx) with the sick visit.

Special needs: Any special-needs child, such as a child with cerebral palsy, will usually warrant a sick visit, Scott says, although you [...]