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 must again rely on documentation to provide justification. No payer should dispute this, although some will ask that the child enroll in a program dedicated to management of the specific condition.

Significant behavior problems: A 13-year-old is experiencing problems at school, and has been neglecting homework and failing classes. The child has been involved in dangerous vandalism and displays periodic violent behavior. During a regular well visit, the pediatrician speaks with the child, both individually and in the company of a parent, and afterward counsels the parent alone. The physician considers a referral to a psychologist, but decides to wait. Because of the time spent in counseling, an office visit is warranted. Link 309.xx (adjustment reaction) or 313.xx (disturbance of emotions specific to childhood and adolescence) to the appropriate inpatient E/M code.

Note: Although CPT specifies no time guidelines for preventive medicine services, physicians may use time as a factor in determining the appropriate-level sick visit if counseling consumes more than 50 percent of the sick portion of the visit.

Diabetes mellitus: This chronic condition would always justify a sick visit in addition to a well visit, Scott and Tuck agree. [The physician] needs to check blood sugar monitoring, diet management, and any reactions since the patient was last seen, all of which necessitate extra time and effort, Tuck explains.

Heart murmur: If the pediatrician suspects a pathological murmur, he or she should refer the child to a cardiologist. Nevertheless, the pediatrician will likely spend significant time providing counseling and explanations to the parents, says Charles Schulte, MD, FAAP, chair of the AAP committee on coding and reimbursement, and CPT advisor for the AAP.

Note: A sick visit may not be warranted for a normal or functional heart murmur. If the pediatrician orders an electrocardiograph or x-ray to rule out a pathological murmur, however, he or she should bill a sick visit.

Significant colic: In infants, colic would warrant a sick visit in addition to the well visit. Theres no lab testing, but there would be a discussion of possible formula changes and general management of the colic, Tuck says. Additionally, he continues, there is an additional history and extra time spent counseling the parent. Link diagnosis code 789.0x (abdominal pain) to the sick visit.

Use Caution When Billing Separate E/M

If a problem uncovered during a well visit does not meet the significant and separately identifiable criteria necessary to append modifier -25, only the preventive service may be billed.

The following examples typically would not warrant a sick visit code in addition to a well visit:

Upper respiratory infection (URI): A 15-month-old child is brought to the pediatrician in December for a preventive medicine service and shots. Although otherwise healthy, the child has a cold. A sick visit is not justified because (1) the parent would not have brought the child to the pediatrician for a cold alone; (2) URIs are common, especially during the winter months; and (3) there is no justification for billing even the lowest-level office visit.

However, if the pediatrician must delay immunizations due to the URI (an uncommon occurrence), the illness is severe enough to warrant a sick visit. If the pediatrician uncovers another problem such as serious temper tantrums at the same time, this additional problem, when combined with the URI, may raise the level of E/M and he or she might consider billing a sick visit.

Contact dermatitis: Whether diaper rash or another localized rash, this condition would probably not warrant a separate E/M visit when presented during a well visit.

Infant feeding problems: Unless associated with serious problems such as failure to thrive, these problems do not justify a sick visit in addition to a well visit.

Normal (vibratory) heart murmur: When a heart murmur does not result in a referral to a cardiologist, it does not usually entail more work. One might argue, after all, that the very purpose of a well visit is to uncover silent problems like heart murmurs.

Pediatricians Must Exercise Judgment

As is usual in coding, there are gray zones. Otitis media, gastroenteritis and fussy infant are common examples of conditions that may sometimes call for a sick visit when encountered during a well visit. In the case of otitis media, for example, the child may have had many ear infections in the past. The pediatrician may decide its time to refer the child to an ENT for possible tubes. This referral, and the discussion with the parents, definitely adds a sick visit to the well visit, Scott says.

On occasion, pediatric practices receive a call from a parent asking, Im coming for a checkup tomorrow, but my baby is sick now. What should I do? If the problem sounds like a viral illness, the pediatrician might suggest that the parent raise the issue during the well visit. You would have seen the child for a sick visit anyway, Scott reasons, but because the well visit is scheduled, you do it then. Once again, documentation and the significance of the new problem determine if an additional sick visit is justified.