Pediatric Coding Alert

Question: A patient came in for a physical exam. While there, one of our physicians also diagnosed the patient with a sore throat. What is the best way to code for this scenario?

Massachusetts Subscriber

Answer: To arrive at a definitive conclusion, you’ll need to answer several questions about the patient.

Ask these Px status questions: You can code the exam in several different ways, assuming it is preventive in nature. If the patient is a new patient, you would use 99381-99387 (Initial comprehensive preventive medicine evaluation and management of an individual …); if the patient is established, you would use 99391-99397 (Periodic comprehensive preventive medicine reevaluation and management of an individual …). The exact code would then be determined by the patient’s age per the codes’ descriptors.

Add problem-focused E/M: Mary I. Falbo, MBA, CPC CEO of Millennium Healthcare Consulting, Inc., in Lansdale, Pennsylvania, notes that “if the patient complaint requires additional workup, beyond that usually associated with the preventive service, you may choose to report a problem-focused E/M service in addition to the preventive service.”

So, per the CPT^® codebook, you should report the appropriate Office/Outpatient code from the 99201 (Office or other outpatient visitfor the evaluation and management of a new patient, which requires these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making …) through 99215 (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 comprehensive history; a comprehensive examination; medical decision making of high complexity …) code set, depending on encounter specifics. Also, you’ll need to provide documentation of a separate history of present illness (HPI) to support both services.

Accurately document the patient’s condition: You’d code a recent onset of sore throat with the J02 category (Acute pharyngitis …) codes. If the cause of the sore throat is not specified, you would code J02.9 (Acute pharyngitis, unspecified), but if the physician does identify the cause of the sore throat, you can go further and code J02.0 (Streptococcal pharyngitis) or J02.8 (Acute pharyngitis due to other specified organisms), depending on the notes.

Remember: If J02.8 is the correct code to use for the patient’s diagnosis, you won’t be able to use any of the other codes outside of the J02 category, as J02.8 excludes you from using any additional code.

J02.8 can then be accompanied by additional codes in the B95-B97 (Bacterial and viral infectious agents) categories to pinpoint the exact bacterial or viral agent. But if the sore throat is symptomatic of another illness, you might code it as:

• acute pharyngitis due to gonococcus (A54.5);
• acute pharyngitis due to herpes [simplex] virus (B00.2);
• acute pharyngitis due to infectious mononucleosis (B27.-); or
• enteroviral vesicular pharyngitis (B08.5).

And if this is not the first time the patient has experienced the condition, then J31.2 (Chronic pharyngitis) may be the most accurate way to code it.

Modifier 25 to the rescue: The key to coding the whole scenario, however, lies in appending 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) to the problem-oriented E/M service (99201-99215) in this scenario. This acknowledges that your physician provided an additional, separate service on the same day as the physical.