Pediatric Coding Alert

Question: We had a patient today who needed a complete physical and shots for kindergarten. Her last pediatrician visit was on September 10, 1999. According to her HMO, todays visit [in June, 2000] cannot be billed as a physical, because it has not been 12 months since the last one. The school insists she have a complete physical and her shots before entering kindergarten. The doctor could find absolutely nothing wrong with the child and no history from the parent about any concerns. Although a complete physical was done, including an eye exam, we will have to code as a regular office visit. What can we use as a diagnosis for this visit?

New York Subscriber

Answer: When this kind of service is provided it would be beneficial to have a system in place to detect frequency patterns of well-child exams. However, subscribers are supposed to be informed of their coverage so the parents should have known that only one well-visit a year was covered for that age group.

Even though the physical is a requirement to enter school, communication between the parents and the school regarding the possible non-payment of the physical by the insurance carrier would be well understood and the physical could probably be scheduled after school had begun to meet the correct time frame.

These services should be coded accurately to reflect the work done, regardless of the coverage. The ICD-9 code should be V20.2 (routine infant or child health check) for a well-child exam. Use individual codes for each immunization injection administered. The correct preventive-care code would be selected for the visit.

These services will undoubtedly be denied but will show what was actually done. It is the parents responsibility to know and understand the preventive-medicine- services benefit. Since this was performed before the time parameter the parent is accountable for the payment. When the child comes in, make sure the office manager discusses this with the parent to avoid possible problems later on when you bill.

Answers to You Be the Coder and Reader Questions provided by: Richard H. Tuck, MD, FAAP, founding chair, AAP coding and reimbursement committee; Thomas Kent, CPC, CMM, president, Kent Medical Management, Dunkirk, Md.; Richard A. Molteni, MD, FAAP, CPT editorial panel member, vice president and medical director, Children's Hospital and Regional Medical Center, Seattle, Wash.; Susan Callaway-Stradley, CPC, CCS-P, independent coding consultant, North Augusta, S.C.; Ellen North, CPC, CPC-H, senior consultant/manager, Intermountain Healthcare; Linda Jackson, CPC, CCS, Medicare consultant, Iowa Veteran's Home.