Pediatric Coding Alert

Read thoroughly to determine whether you can see where this practice forfeited money.

When you’re coding your pediatrician’s charts, you may simply rely on the doctor’s code selections. But if you look deeper, you may find opportunities to report additional codes and bring more money into your practice. Check out the following pediatric note as submitted to Pediatric Coding Alert, and determine whether you can spot where the coding went awry.

Code reported: 99392

HPI: This 14-month-old female patient presents for her well-child 12 month visit. She is still on breast milk about six times per day. She sleeps all night and has done so since age four months. She is already saying a few words such as “mama” and “dog.” She has had a runny nose for two weeks, with nasal congestion that has gotten increasingly worse. In addition, she has a diaper rash that was bleeding two days ago.

Past medical history: Reviewed from her Oct. 1, 2013 visit. No changes.

Family/social history: Her father has a history of testicular cancer and her mother has had two squamous cell melanomas removed. She lives with both parents and a healthy five-year-old brother. She is home with her mother during the day and socializes at a playgroup but does not go to school or day care. She has never been on antibiotics and has not yet tried solid food.

Medication: Sodium fluoride 0.5 mg fluoride drops (1.1 mg/mL) daily

Allergies: NKA.

All areas of development are appropriate for her age. 

Exam:

Musculoskeletal: Overview: normal. Gait: normal

Skin/hair: Mild candida diaper rash. Otherwise normal.

Constitutional: Level of distress: Normal. Nourishment: Normal. Overall appearance: Normal

Head/face: Anterior fontantel: Open, soft. Skull: Normal.

Eyes: Pupils, conjunctiva, sclera, ocular muscles normal

Ears: Right: normal. Left: TM is dull and erythematous, but canal is normal.

Nose/mouth/throat: Both right and left nares are showing clear discharge. Oropharynx, lips/teeth/gums, palate, uvula and tonsils are normal.

Neck/thyroid: Normal

Lymphatic: Normal

Respiratory/thorax: Auscultation: Normal. Cough: Absent. Effort: Normal

Cardiovascular: Heart rate and rhythm are normal. No murmurs

Extremity: No cyanosis, clubbing or edema

Vascular: Pulses: Brachial and femoral normal

Abdomen: Inspection and anterior palpation normal, with no abdominal tenderness or guarding

Psychiatric: Behavior appropriate for age.

Assessment: Routine child health exam (V20.2), Otitis media NOS (382.9) and Diaper or napkin rash (691.0). 

Prescribed Amoxicillin 125mg/5ml 3 times/day and nystatin 100,000 unit/gram topical ointment 4 times/day. Routine advice and care were given with information on how to wean from breast to a cup. Vaccines postponed due to mother’s concern about the child’s other conditions.

Spot the Problems

This chart is very well documented, and the notes do justify 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual…). Unfortunately, however, the practice failed to recognize an opportunity to also report a sick visit. 

Here’s why: The physician performed the complete well child exam and also addressed the patient’s ear infection and diaper rash, prescribing two medications to treat those conditions. Therefore, you should report both the sick and well visits, not just the well child exam. In this case, the notes qualify for 99213 as well as the 99392.

Revenue loss: Failing to report 99213 cost the practice about $73.00, depending on the office’s geographic location.

Don’t forget modifiers: To report both the well visit and the sick visit, you should append modifier 25 to the sick visit code. So your coding will appear as follows:

99392 linked to V20.2

99213-25 linked to 382.0 and 691.0.