Pediatric Coding Alert

Question: How can I tell if a problem found at a preventive medicine visit is considered significant?


California Subscriber
Answer: Knowing whether a problem is significant is critical to your coding of the session. If the problem or abnormality is significant, you should code the appropriate E/M visit (such as 99201-99215, Office or other outpatient services) in addition to 99381-99384 or 99391-99394 (Preventive medicine services). In these instances, you use modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) on the sick visit code to indicate the problem is significant and separately identifiable from the preventive medicine service.

If the problem is not significant, you should report only 99381-99384 or 99391-99394.

You should consider a problem significant if you can answer "yes" to these items:

• a return visit would be required for the problem

• a prescription is required

• a significant amount of distinct time is devoted for counseling and coordination of care for the problem

• there is a separate supporting ICD-9 diagnosis

• there is separately recorded documentation for the problem. Option: If an insurer doesn't cover two same-day services, consider these alternatives:

1. Have the patient return for a separate E/M visit for the problem/abnormality found.

2. Address the problem only and have the patient return for the preventive medicine service.