Pediatric Coding Alert

Question: We frequently have babies present for well visits but the doctor finds a problem during the encounter. We want to report both the sick and well codes, but the pediatrician believes we should just increase the level of the preventive visit code. Who is right?

Answer: You are. If a child presents for a physical and the pediatrician finds a problem that prompts a separate sick child evaluation, you may waffle on whether to report both the sick and well E/M codes—but the AMA actually addresses this situation specifically, and advises you to bill both codes.

In black and white: “If the problem is significant enough to require additional work for the physician to perform the key components of a problem-oriented E/M service, the appropriate office/outpatient code (99201- 99215) should be reported, in addition to the appropriate code for the preventive medicine E/M service, and modifier 25 should be added to the office/outpatient code,” the AMA says in the July 2009 issue of CPT® Assistant.

In addition to appending modifier 25 to the sick visit code, you should ensure that your documentation provides proof that the pediatrician performed both services and they were significant and separately identifiable. “In order for the two E/M services to be reported on the same day, the problem or abnormality encountered must require additional work effort by the physician, and the performance of the key components of a problem-oriented service outside of the health supervision work inherent in the preventive medicine E/M service,” the CPT® Assistant article says. Remember also that when doing a sick visit at the same time as a physical, the physician will typically need to base the code on history and medical decision making (MDM) as there is no medical necessity to redo the physical.

If, however, the pediatrician finds something insignificant—such as a benign-looking mole that requires no additional evaluation or refilling a medication for a chronic but stable illness—that would most likely be included in the preventive visit code and you couldn’t separately report a sick visit for it.

Also, there is no way to increase the level of preventive care, as those codes (99381-99387 for new patients and 99391-99397 for established patients) are all based on age and not by criteria.