Pediatric Coding Alert

Question: Our pediatrician often performs initial comprehensive preventive medicine services for patients. If the patient has a problem-focused complaint during one of these preventive encounters, can we report a preventive care code and a separate evaluation and management (E/M) service?

Hawaii Subscriber

Answer: You may be able to report a problem-oriented E/M in addition to a scheduled preventive care visit when a patient comes in for an initial preventive exam. According to CPT^® 2017, to qualify for an additional E/M, “the problem must be significant enough to require the additional work of a problem-oriented E/M service.”

So, let’s say that your pediatrician performs a periodic comprehensive exam for a 12-year-old established female patient. During the encounter, the patient complains of right shoulder pain. Encounter notes indicate that after the initial exam, the provider performed a separate problem-focused exam and history to address the patient’s shoulder pain.

First, you would report 99394 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent [age 12 through 17 years]) for the initial exam with Z00.121 (Encounter for routine child health examination with abnormal findings) appended and M25.511 (Pain in right shoulder) to represent the reasons for the visit.

Then, provided the notes support the preventive visit and the separate E/M, you report 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) for the E/M with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to show that the E/M and preventive exam were separate services.

Also, append M25.511 to 99212 to represent the patient’s shoulder pain.

Remember: Separate the encounter notes to indicate that the provider performed two very, distinct separate services on the same date. If you only submit one encounter note, however, be sure that the documentation reflects a distinct delineation between the two services.