Pediatric Coding Alert

Tip: Keep an eye on the clock to ensure you’re billing accurately for time spent.

It’s hard enough to determine when you can report both a sick and well child visit during the same encounter, but even more challenging if you plan to bill just one of those codes based on time. Check out this scenario to help you code these notes.

Scenario: A mother brings her child to the office for a 9-month well visit. Additional diagnoses from the visit include failure to thrive (FTT), established diagnoses of eczema and reflux, and feeding problems. The mother declines reflux medications and UGI (upper gastrointestinal) tests at earlier visits, and refuses to see a dietitian. The pediatrician spends approximately 1 hour and 15 minutes total with the patient and her mother. She documents spending 45 minutes on feeding/eczema discussions. Documented services include:

• Writing a prescription for eczema treatment
• Performing a complete physical exam and anticipatory guidance due to the well visit
• Discussion on FTT and eczema issues on a separate progress note.

Challenge: The physician wants to charge a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) in addition to the well visit code. Remember, however, that the well visit E/M code includes much of the exam the pediatrician completed, so reporting both might be tricky.

Plan Ahead With Separate Documentation

When you document complicated visits, think ahead to how your documentation can make coding easier. For example, in this scenario, document both parts of the visit separately (30 minutes for the well visit and 45 minutes for eczema and feeding education).

Here’s why: Separating the standard well visit services from the additional education and care make it easier to track the amount of time associated with each part of the patient’s visit. Documenting those details helps you code more accurately and explains the situation in case you’re audited later.

Feel Confident With 99215, 99391

Although this physician wanted to report 99214 for the E/M service, he actually provided enough care to merit 99215 (Office or other outpatient evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity) as well as the preventive visit.

Explanation: The CPT descriptor for 99215 states, “Typically, 40 minutes are spent face-to-face with the patient and/or family.” The pediatrician’s services clearly support time-based coding because the counseling and coordination of care for failure to thrive and eczema constitute more than 50 percent of the documented face-to-face time spent addressing the problems (45 of the total 75 minutes). Therefore, you can legitimately report 99215.

Keep in mind that the physician must document the total amount of time and the amount of time spent in the counseling. For example, “Total time in visit with well care and sick care 1 hour and 15 minutes, with 45 minutes spent specifically in the sick visit concerning FTT and eczema. Greater than 50 percent of the 45 minutes was spent in counseling concerning the FTT and eczema.” Follow this with a description of the counseling topics.

Don’t forget: Submit 99215 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service). Report the well visit with 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction, interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant [age younger than 1 year]).

Link Diagnoses for Each Condition

Complete your claim with the correct diagnoses for each aspect of the patient’s care:

• Link V20.2 (Routine infant or child check) with 99391 for the well check
• Link diagnoses for the other conditions to 99215.

Diagnoses addressed and counseled for 99215 include 783.41 (Failure to thrive), which you should list first as it is the “highest” diagnosis in this category. In addition, report 530.81 (Esophageal reflux), 691.8 (Other atopic dermatitis and related conditions) for eczema and 783.3 (Feeding difficulties and mismanagement).