Pediatric Coding Alert

Pediatricians who perform pelvic exams on teens must code carefully to avoid fraud while maximizing reimbursement for this time-consuming service. Ironically, there is no CPT code for a pelvic exam. However, coding solutions such as using high-level E/M codes can facilitate reimbursement.
 
"Pediatricians have difficulty choosing procedure and diagnosis codes for a pelvic with no symptoms," says Thomas A. Kent, CMM, CPC, president of Kent Medical Management in Dunkirk, Md. Below are the circumstances, with coding recommendations, under which pediatricians perform pelvic exams.
Simple Exam During a Well Visit  
A pelvic exam is included in a visit for preventive-medicine service: 99384 (new patients ages 12-17), 99394 (established patients ages 12-17), 99385 (new patients 18-39) or 99395 (established patients 18-39). You cannot bill separately for a pelvic exam unless the patient has a medical problem or complaint. Then you can bill a sick visit (99201-99205 for a new patient, 99212-99215 for an established patient).
 
For example, if the pediatrician performs a complete preventive-medicine service (well visit) and a pelvic exam because the patient is sexually active, report only the appropriate preventive-service code. Do not report the pelvic exam separately as a sick visit. Use ICD-9 code V20.2 (routine infant or child health check) with the well visit.
Use Specialized Codes  
A Pap smear with a pelvic exam, for a child with no medical complaints, should be coded V72.3 (gynecological examination). "Do not use V20.2," Kent says.
 
Sometimes pediatricians feel they shouldn't use ob/gyn codes like V72.3. But physicians should use the correct diagnosis codes, notes Richard H. Tuck, MD, FAAP, founding chairman and a member of the AAP coding and reimbursement committee. "Be sure to follow carrier-specific guidelines regarding Pap smear and pelvic exam codes. But if a pediatrician performs a Pap smear, he or she should charge for it using the correct diagnosis code (V72.3)," Tuck says, comparing this situation to a family practice physician who performs a c-section even though the physician is not an ob/gyn.
 
Pediatricians, however, can't report the preventive-medicine services codes for purely gynecological exams. Instead, they should bill an office visit (99201-99205, 99212-99215) for a gynecological exam, Tuck says.
 
For example, a teen-age girl comes in for a gynecological exam and has no medical complaint. Perhaps she wants birth-control pills. Bill an office visit (i.e., 99213 or 99214), linking it with V72.3. If counseling predominates the session, the pediatrician can select the level of E/M based on time.

Coding Medical Problems  
If the patient needs a pelvic exam due to a medical complaint such as [...]