Pediatric Coding Alert

Question: A 2-year-old established patient presented for a preventive medicine service. The patient's mother mentioned that the child had been holding her arm funny and complaining of pain for the past two days after rolling off the top bunk bed. The pediatrician further evaluated these symptoms, ordered an x-ray, and referred the patient to an orthopod. The physician then completed the well check. Should I separately code an E/M for the arm-related complaint?

Utah Subscriber

Answer: You should code an office visit for the problem-oriented evaluation and management service, provided the documentation reflects the details that you mention. Signs that indicate a 9921x-25 (Office or other outpatient visit for the evaluation and management of an established patient ... Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appropriate include a chief complaint (arm pain), evaluation of these symptoms, and follow-up work ordered (an x-ray and possibly a referral).

Make sure you link the problem-oriented office visit to the problem and the preventive medicine service to the V code. Your claim could include:

• 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... early childhood [age 1 through 4 years]) for the well check with V20.2 (Routine infant or child health check)

• 9921x-25 linked to 729.5 (Pain in limb) and possibly E884.4 (Fall from bed).