Pediatric Coding Alert

Question: Our pediatrician saw a newborn as a quick assessment within a few days of birth at no charge. The mother returned with the baby at two weeks for a complete exam. Should this be billed as an E/M service, and if so, should it be established or new?

Missouri subscriber

Answer: When the visit is a follow-up to an identified problem such as jaundice, infrequent stools, or infrequent feedings, and the physician, nurse practitioner, or physician assistant provides the service, an office visit (eg, 99212-99215) and problem-specific diagnosis codes should be reported. The patient will be considered "established" because you already treated the patient during a face-to-face encounter within the last three years, which constitutes an established patient under the CPT guidelines.

If no feeding or other significant health problem was previously noted, this visit may be the first well-child visit when provided by a physician, nurse practitioner or physician assistant. Code 99391 may be reported with diagnosis code V20.2 for this service. This service includes time spent addressing routine feeding issues and anticipatory guidance. However, if significant time beyond that typical of the infant preventive service is spent in counseling for a problem or specific concern, physicians may also report a problem-oriented service (99212-99215) with modifier 25 to indicate the significant and separately identifiable services provided on the same date.

Documentation should include approximate time spent face-to-face with the family and patient, notation of time spent in counseling and context of counseling. (Codes may be selected based on time spent in counseling and coordination of care when documentation indicates more than 50% of face-to-face time was spent in these activities.)

If a nurse visit is provided (e.g., weight screen only), code 99211 may be reported. If the nurse visit results in a visit with the physician, only the physician services would be reported.