Pediatric Coding Alert

Ask, “is the problem significant or trivial?”

Preventive visits that uncover a serious, significant condition don’t happen very often. But they do happen, and when they do, they need to be coded accurately.

That means going beyond simply billing a well visit and appending modifier 25 (Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service) onto a problem-oriented evaluation and management (E/M) service code.

To help you code these encounters correctly, we’ve assembled a number of frequently asked questions and some scenarios along with some definitive answers and expert opinion to help you see how coding these encounters will get easier in 2021.

When Can I Code Well Visits With Sick Visits?

CPT^® guidelines tell you that “if an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service,” then you may code both the well visit, or preventive E/M, and the sick visit, or problem-oriented E/M, together.

Conversely, the guidelines continue by telling you that an “insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”

So, much of the confusion over knowing when to report a well visit with a sick visit comes in determining whether a problem uncovered during the well visit is “significant” or “insignificant or trivial.”

What Constitutes a Significant Problem?

Consider this example: A patient presents for a four-year well visit, and during the visit, the patient’s mother tells the provider that the child started with a fever that morning and that their left ear began hurting. The pediatrician notes in the history that the patient has had ear infections previously. The pediatrician performs all the components of the preventive visit and an exam, which results in a diagnosis of left-sided suppurative otitis media. The pediatrician orders an antibiotic for the condition.

“In this scenario, under the 2020 office or outpatient E/M guidelines, you wouldn’t be able to count the exam twice. But based on an expanded problem-focused history and low medical decision making [MDM], you could bill the sick visit with 99213-25 [Office or other outpatient visit for the evaluation and management of an established patient …] along with the well visit using 99392 [Periodic comprehensive preventive medicine reevaluation and management of an individual … early childhood (age 1 through 4 years)],” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

And don’t forget: As the abnormality is significant enough to require the additional work to justify reporting the sick visit, you’ll report Z00.121 (Encounter for routine child health examination with abnormal findings) with the 99392.

Will This Change in 2021?

No. In fact, it will get easier to bill a well and sick visit together if the situation arises. That’s because, unless you opt for coding the sick visit by time, “the sick portion of the visit will be based strictly on MDM, and history and exam will no longer be factors in determining the level billed,” Holle notes. In our scenario, the level of visit will not change, however, and you will still report 99213-25 due to the low level of MDM (as only one of the two elements — the prescription drug management — exceeds the level).

When Can a Well Visit not Be Coded With a Sick Visit?

Consider this example: A 6-month-old presents for their preventive visit and immunizations. During the exam, the provider notices that the baby has a diaper rash that Mom states just started that morning. The pediatrician creates an assessment and plan, counsels the mother on the vaccines, and also advises her to use diaper cream on the diaper rash and to call if this rash gets worse over the next few days.

“In this case, you would bill only the 99391 with Z00.121 and L22 [Diaper dermatitis], as the diaper rash would be regarded as ‘insignificant or trivial,’” says Holle.

How Often Should I Be Coding Well Visits With Sick Visits?

Just because you can code preventive and sick visits together doesn’t mean you should be doing it a lot. In fact, benchmarking data suggests the combination of coding a preventive visit with a sick visit is pretty rare in pediatrics. “About 55 percent of our clients billed about 5 percent of their well visits with an additional sick visit,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant.”

“There are practices who are billing as many as 45 percent … or even more than 70 percent of their well visits with an additional sick code. But they are not common. The bottom line is that our clients code a sick visit during a well visit 5.7 percent of the time,” Hart notes.