Pediatric Coding Alert

Can you provide the correct ICD-10 and CPT^® codes for these 2 scenarios?

Time to test your preventive medicine evaluation and management (E/M) service smarts. The following two scenarios each present challenges in determining what constitutes an abnormal finding in a preventive E/M encounter, and how and why you can report other services in addition to the preventive encounter.

Scenario 1: Your pediatrician examines and discharges a normal newborn from hospital. A week later, the newborn presents for their first preventive medicine service at your practice. The pediatrician performs a routine post-discharge exam, but notices the baby has an umbilical granuloma, which the pediatrician treats using a topical application of concentrated silver nitrate solution. What codes would you assign to this encounter?

Scenario 2: The same child presents for immunizations at seven weeks, and during the exam, the pediatrician detects the very mild beginning stage of a diaper rash. The pediatrician tells the parent to use over-the-counter barrier protection and leave the baby undiapered to air out after each diaper change. The pediatrician then immunizes the child with diphtheria, tetanus, pertussis, type B influenza, polio, hepatitis B, pneumonia, and rotavirus vaccines; and counsels the mother about the vaccines. What codes would you assign to this encounter?

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