Pediatric Coding Alert

Question: If a child comes in for a well visit and it turns out that the child is sick (for example, with an ear infection) should we code a well or sick visit? How is the follow-up coded (the child is seen for an ear recheck but if the ear is clear will be given an immunization)?

Arkansas Subscriber

Answer: For the initial encounter, code the preventive medicine services visit on the first line and the sick visit, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or service), on the second line. Modifier -25 requires that the sick visit be a significant and separately identifiable service from the preventive medicine services (some coders feel that prescribing medication is enough to qualify for billing the sick visit). Use ICD-9 V20.2 (routine infant or child health check) for the preventive medicine services visit, and the appropriate diagnosis for the sick visit. A follow-up visit for an ear infection will use the otitis media diagnosis again. The ICD-9 system does not include a code for resolved problems; simply repeat the same diagnosis code, as well as V67.9, for a follow-up visit. A resolved problem will have a lower-level office visit than an unresolved illness.

For the immunizations, use the appropriate immunization CPT and diagnosis codes.