Pediatric Coding Alert

Question: One of our young patients just came back for a recheck after being diagnosed with otitis media (OM) ten days earlier. The pediatrician found that the condition had cleared up and gave the patient a clean bill of health. Do I document this encounter with the same diagnosis as the initial encounter and add that the condition has been resolved in the notes? And if I document that the patient no longer has the condition, can I also bill an evaluation and management (E/M) service for the recheck?

North Carolina Subscriber

Answer: As the patient no longer had the condition at the time of the encounter, you cannot code for it. Instead, you would code Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm). And if the patient has a history of OM, you can also code Z86.69 (Personal history of other diseases of the nervous system and sense organs).

The visit should also be reported with the appropriate low-level, established patient E/M service code. In this case, given that your provider may have only conducted two out of the three components, such as a problem-focused history and a problem-focused exam, the visit should qualify for a 99212 (Office or other outpatient visit for the evaluation and management of an established patient …).