Pediatric Coding Alert

Question: Does reporting an established patient preventive medicine service and a problem-oriented visit on the same day require two copayments?

Texas Subscriber

Answer: The individual payer and plan determine whether one or two copayments apply to 9939X (Periodic comprehensive preventive medicine reevaluation and management of an individual ...) and 9921X-25 (Office or other outpatient visit for the evaluation and management of an established patient ...; Significant, separately identifiable evaluation and management service on the same day of the procedure or other service).

Make sure you have documentation that supports the problem-oriented service as significant and separately identifiable from the preventive medicine service (such as 99392, ... early childhood [age 1 though 4 years]). Separate documentation with chart notes that show the history, examination, and medical decision-making involved in the chosen level of office visit will help in the event of denial for same-day E/M services.

To combat issues with two copays, consider two approaches:

1. Give the parent the option of having one service today and returning for the other.

For instance, if the child has an ear infection (such as 382.9, Unspecified otitis media), the pediatrician could offer to treat that and reschedule the patient for the preventive medicine service. In this case, you would report only the sick visit (such as 99213) and the guardian would be subject to one copay.

Don't miss: Explain that if the parent opts for the convenience of continuity of care and elects to have both services today, which is medically permissible, the parent may be responsible for two copayments due to the insurer and plan applying preventive and "sick" benefits separately. Assure the parent that collecting copays is a contract that you are obligated to follow. In this scenario, you would report both E/Ms (9939X and 9921X-25).

2. Post a policy in your office or in your handbook that you have new patients sign explaining that some insurers may apply two copayments to well checks and sick visits. Notify parents that it is their responsibility to know what their plans cover; if parents prefer to reschedule one of the services, they should alert staff to that decision.

Some plans specify that there is only one copay for E/M services on a given date. If, however, the software says to collect a copay for each E/M code, collect the additional copay and have the patient pursue the issue with her plan.