Pediatric Coding Alert

Question:  Our practice in in a heated discussion about an issue and we can’t come to an agreement. Our physician performed an annual physical and is planning to report a well-child code for it. In addition, he is going to perform a pre-operative exam to give surgical clearance for the patient’s tonsillectomy on the same date. Our pediatrician wants to bill for that (using consult code 99242 with V72.83) and then also bill for the well child visit with 99393. Can we bill for both if they are on the same date of service? 

Answer:  No, you should not report both codes. You should report the appropriate well visit code (such as 99393) along with the V codes for both services—V20.2 (Routine infant or child health check) first, followed by the reason for the surgery (for instance, chronic otitis media, 381.x) and then V72.83 (Other specified preoperative examination). A consultation requires all three key factors be present: history, physical and medical decision making (MDM). When doing well care, the physical is already performed so you could not report both a consult at the same time as any well care code. However, the additional work required of a pre-op visit could potentially raise the preventive visit level (assuming the documentation is thorough) but would not typically warrant the use of a second CPT® code.

If the physician believes that he performed other services during the pre-op exam that aren’t covered by the preventive visit code, you could consider reporting the well care with a sick visit code (99212-99215), which only requires two of the three key factors, allowing you to use the history and MDM in selecting the level of care. You’ll bill the well care with V20.2 and the sick visit with the reason for the surgery and the V code for the pre-operative clearance for surgery as above. In addition, you must maintain two separate notes showing that two distinct services were performed to justify reporting both codes. You’ll also need to append 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 sick visit code.