Pediatric Coding Alert

Question: We've found increased BMI during well visits for several children lately. The pediatrician spends additional time on discussion, referring the child to a dietitian, and scheduling lab tests. We're having trouble deciphering the amount of documentation needed and when we're justified in coding a higher level E/M visit. What should we keep in mind?

Oklahoma Subscriber

Answer: Base your codes for this type of significant, distinct problem on the amount of time spent on counseling and coordinating care. If your pediatricians do their own coding, they know how much extra time and effort went into the counseling so should code accordingly. If your providers don't do their own coding, train them to make a note in the chart regarding how much extra time they spent with the patient addressing the problem.

Once you know the timeframe, you can choose the appropriate code. You'll probably report 99212 (Office or other outpatient visit for the evaluation and management of an established patient ...) or 99213 most often. Code 99212 typically represents 10 minutes of additional face-to-face time spent counseling with the patient; 99213 typically represents 15 minutes. Remember to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to whatever E/M code you choose.

You'll also report the age-appropriate code for preventive medicine services. For a new patient, choose from 99381- 99384 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient ...). Established patient codes include 99391-99394 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient ...).

Tip: Your provider might want to mention something to the parents about the "extra time" she spent on the visit. Make the parents aware that the insurance company might not pay for the extra time, so they know you might charge them for a noncovered service.