Pediatric Coding Alert

Question: Our pediatrician just saw a 4-year-old patient for a new patient well-child check. Due to a traumatic experience at a previous pediatrician’s office, the child began screaming while being touched and would not allow our physician to complete the exam. However, our pediatrician noted some minor developmental delays based on the Mom’s completion of an Ages and Stages Questionnaire (ASQ).

At the end of the encounter, our pediatrician spent some time counseling Mom on ways she can work with the child to make the child more comfortable for the next appointment, scheduled in two weeks, where they will complete the well-child visit and discuss exercises the two can do to overcome the developmental delays.

My question is: Does this service qualify for billing a separate, significant evaluation and management (E/M) service in addition to the well-child visit?

New Jersey Subscriber

Answer: There is probably not enough in the note to document both a preventive care visit and a sick visit. You would have to document key components separate from the components in the preventive history and exam, along with medical decision making, or separate counseling or coordination of care for a different, identifiable problem.

Of greater concern is the fact that your pediatrician was unable to complete the exam. A full, unclothed examination is a necessary component of the Early and Periodic Screening, Diagnostic and Treatment (EPSDT), which is the child health component of Medicaid. Without it, Medicaid and payers following their guidelines may not reimburse you for the well-child check.

One solution to this encounter would be to document an appropriate E/M from 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) for this visit linked to an appropriate diagnosis such as F40.232 (Fear of other medical care), then bill for the preventive exam at the subsequent appointment once your pediatrician completes the age- and gender-appropriate exam.

If you do go this route, bear in mind that the 99201-99205 codes require all three key components, so a physician exam would have to be present. As the child would not allow an exam to take place, your best bet would be to use time as the key factor in determining the level of the visit. More than likely, this would be the situation due to the counseling that resulted from the screening and the child’s aversion to your pediatrician’s physical exam.