Pediatric Coding Alert

Question: When a new patient is scheduled for an initial physical exam and the pediatrician also addresses a problem during that exam, is that problem going to require a second evaluation and management (E/M) code?

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Answer: Whether you report a second E/M for the evaluation and management of the problem depends entirely on the problem presented.

For example, if the pediatrician performed all the standard elements of a wellness visit— such as an age-appropriate history, exam, counseling/anticipatory guidance/risk factor reduction, and the ordering on appropriate labs or diagnostic procedures on a 14-year-old patient who identifies as female — and the patient expressed concern that they hadn’t yet started menstruating, that conversation would not likely warrant an additional code of any kind. This is because addressing menstruation would be part of that wellness visit already, and the doctor would not likely consider that a developmental delay of any kind, so no further examination would be necessary. For this encounter, you’d simply code the new patient physical, such as 99384 (Initial comprehensive preventive medicine evaluation and management of an individual… new patient; adolescent (age 12 through 17 years)).

On the other hand, let’s say the pediatrician performed all the elements of a standard wellness visit, and then the patient mentioned some ongoing pain in their right ear. When the pediatrician looked in their ears, he noticed significant wax buildup, but it wasn’t impacted. He decided to flush it out, then had a separate conversation with the patient about their history of wax buildup and ear pain, whether they were doing anything to control the buildup, and suggestions for how to manage excessive earwax production going forward to avoid future discomfort.

This scenario would require you report the new patient physical first with 99384, because that’s the reason for the encounter. Then you’d need to report the wax removal, about which CPT^® guidelines say the following: “for cerumen removal that is not impacted, see E/M service code.” That would mean using the appropriate evaluation and management (E/M) code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …).

Remember also, that because the E/M was significant and separately identifiable, you’d 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 E/M if the documentation adequately supported how the E/M service for the earwax was separate from the discussions and evaluations involved in the wellness exam.