Pediatric Coding Alert

Question: One of our high-school-age patients is preparing for a monthlong trip to Kenya. She met with our pediatrician to discuss vaccinations and medications she may need for the trip, but she was not vaccinated at the time. How should we document this encounter?

Virginia Subscriber

Answer: Providing the main purpose of the visit is for counseling, the patient has no medical problem, and no vaccination occurred during the meeting, you should look to 99401 through 99404 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure) …).

Just make sure that the amount of time you document for the encounter meets the minimum time of the code you choose:

• 99401 — … approximately 15 minutes
• 99402 — … approximately 30 minutes
• 99403 — … approximately 45 minutes
• 99404 — … approximately 60 minutes.

Then make sure you link the appropriate code to Z71.89 (Other specified counseling).

Resource tip: The Centers for Disease Control and Prevention (CDC) has a comprehensive website devoted to health information for travelers. Your provider can simply go to wwwnc.cdc.gov/travel, select the appropriate country and any travel needs your patient may have (such as needs resulting from a chronic disease or an immune-compromised condition) from the “For Clinicians” drop-down menu. This will direct your provider to a page that contains a comprehensive list of vaccinations and travel counseling that may be appropriate for the patient given her travel destination.