Pediatric Coding Alert

Question: I am providing both preventive healthcare as a physical and preventive gyn/contraception services for my adolescent patients. Since both would be coded as 99394 or a 99395 with a diagnosis code of V70.0 (routine general medical examination at a health care facility), or V20.2 (routine infant or child health check), and V72.3 (gynecological examination), is it best to perform these services on separate days?

Jean M. Petterson, DO
Laconia, N.H.

Answer: Unfortunately, these services will not always get paid. Contraceptive education and counseling are considered a component of preventive care services, and it would be inappropriate to separate these services for the purpose of increasing reimbursement. Yes, some pediatric practices provide preventive medicine services, assign a diagnosis code of V20.2 and reschedule the patient at a later date for a pelvic examination, and then bill an office visit with a diagnosis code, for example of V25.01 (encounter for contraceptive management; general counseling and advice; prescription of oral contraceptives). And yes, some practices reschedule the patient for the gyn exam and the contraception counseling.

But the question is: Is it appropriate to exclude the pelvic examination which is part of the comprehensive preventive medical examination? And is it appropriate to assign an office visit code to a patient who is asymptomatic and without complaint? Probably not. CPT states that initial and periodic preventive medicine services include a history, an examination, counseling/risk factor reduction intervention and the ordering of appropriate laboratory/diagnostic procedures.

If you abide by CPT, the pediatrician would bill the preventive medicine services code for a well visit, which includes a pelvic examination with the diagnosis code of V20.2. The problem with this is that a lot of extra work is involved when a pelvic is done on an adolescent. Unless the patient returns for the pelvic part of the exam, there is no way of capturing the extra work involved for billing purposes.

And another problem is scheduling. So much time is consumed on this procedure that the time allowed just for a well visit is rarely long enough. Richard H. Tuck, MD, FAAP, has had patients come back for another visit, but only if the child is very young and he had not allowed time for the pelvic in the schedule. If the child is 16 or older, the extra time for the gyn exam would be scheduled. For a younger child, it wouldnthence the need to return if there is no time to do it that day. Occasionally, a mother will be very straightforward about it. When scheduling the appointment shell say that she wants her daughter to have a gynecological exam as part of the physical. But if the child does have to come back, he would use an office visitusually 99213 or 99214with the V72.3 diagnosis code. The gynecological exam is included in the preventive medicine services visit, says Tuck. The only way I would have the patient come back is if the exam is unexpected, as in a young teen.