Pediatric Coding Alert

Question: Could you clarify how to code a new patient visit during which the patient comes in for a physical and also to address chronic diagnoses?
 
Example: An adolescent patient is new to the area and makes an appointment with a pediatrician for a yearly physical as well as to discuss chronic diagnoses of asthma and depression. The physician performs the preventive medicine service and has a lengthy discussion with the patient regarding the chronic diagnoses. The documentation supports the physical code and also has enough standalone documentation to bill an E/M with the visit.

Should the pediatrician bill a new patient physical with the appropriate-level new patient E/M? Or should she bill a new patient physical with the appropriate-level established patient E/M?

  
Colorado Subscriber

Answer: The patient remains new throughout the initial encounter, so the pediatrician should code such encounters with 99381-99384 (New patient preventive medicine service) and 99201-99205 (new patient office visit) with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) if you have separate documentation that supports the preventive medicine service linked to V20.2 (Routine infant or child health check) and the separately identifiable problems she addressed (300.4, Reactive depression, and 493.00, Extrinsic asthma; unspecified).

Many practices were actually coding the preventive medicine services as new (99381-99384) and the office visits as established (99212-99215 with modifier 25) until CPT Assistant clarified the issue.

In the October 2006 CPT Assistant's Q&A, the AMA referred to CPT's definition of a new patient as one "who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years." When an office visit follows a new patient preventive medicine service, no professional service has occurred. Therefore, you should consider the patient's status for the encounter, not for the individual portions.

For more information, see February 2007's Pediatric Coding Alert article "Rethink Your Coding of OVs After Well Checks."