Pediatric Coding Alert

Question: When should I bill an office visit in addition to a preventive exam code?

Indiana Subscriber

Answer: You may submit a patient office visit code when your pediatrician encounters an abnormality or addresses a pre-existing problem at a well check (99381-99397). The problem must be significant enough that the pediatrician performs the key components of a problem-related E/M service (99212-99215, Office or other outpatient visit for the evaluation and management of an established patient ...).

Not every problem warrants coding a separate sick visit. For instance, a mother mentions at her 4-month-old daughter's well check (99392, Periodic comprehensive preventive medicine re-evaluation and management of an individual ...; early childhood [age 1 through 4 years]) that the infant has a diaper rash (such as 691.0, Atopic dermatitis and related conditions; diaper or napkin rash). The problem probably doesn't require the pediatrician to perform a low-level sick visit's key components (99212 requires two of these: problem-focused history, problem-focused examination, and straightforward medical decision-making). So, you shouldn't separately report the problem-related portion.

Often, you will code a problem-related E/M service when your pediatrician treats a patient with a chronic condition. Suppose an established diabetic patient (250.01,

Diabetes mellitus without mention of complication; type I [insulin dependent type] [IDDM] [juvenile type], not stated as uncontrolled) presents for his 11-year-old annual exam (99393, ... late childhood [age 5 through 11 years]). The pediatrician checks the boy's blood sugar monitoring, diet management and any reactions since his last visit. Because the additional workup requires a sick visit's key components, you should report the appropriate-level office visit code, such as 99213, in addition to the preventive medicine service. Append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 99212-99215 to indicate that the sick visit is significant and separately identifiable from the annual well exam.