Pediatric Coding Alert

Question: I work at a pediatrician’s office and had an encounter where a patient came in for a well child visit and the parents brought up concern about the child’s hearing. The pediatrician examined the child’s ear in a physical exam and didn’t find anything abnormal. Is this a situation where an evaluation and management (E/M) service code would be appropriate, beyond the regular preventive/wellness exam?

Texas Subscriber

Answer: Examination of the ears is part of the physical exam component of well child visits, and if the pediatrician didn’t perform anything above and beyond what they’d usually do for a well child visit, a separate E/M wouldn’t be appropriate. For example, you don’t mention a hearing test or any other investigation that would extend beyond the scope of a regular well child visit, so you may not have grounds for coding any separate service — or the ability to prove medical necessity to justify the code.

Remember, too, that billing an E/M alongside a preventive visit may mean that the payer won’t cover the service and thus a surprise bill, via co-insurance or deductible, will be sent to the patient/their family. In this situation, it’s best to look at the facts of the encounter and not report an E/M service.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC