Pediatric Coding Alert

Question: A patient came in to our office complaining of constant headaches. During her visit she said she was also having trouble with constipation. Should I be using two office visit codes for this encounter? 

New York subscriber

Answer: You should use one office visit code for this encounter. There are two problems, not two visits. Review the documentation for what should clearly illustrate the multiple issues for a new patient. The note would illustrate the postpartum depression as well as the history elements and examination relevant to the constipation problem. 

The documentation of the history, exam, and medical decision making will guide you to the appropriate level of service (99201-99205, Office or other outpatient visit for the evaluation and management of a new patient, …). Discussing and treating two problems will likely raise the level of medical decision making your physician performed, which typically will support a higher code level if history and exam also meet that level. 

Diagnosis help: You will have two diagnosis codes to attach to your E/M code to show that the provider treated both conditions during the same session. First, you’ll report 784.0 (Headache) for the headache and then 564.0x (Constipation).

This scenario is distinctly different from a preventive medicine visit when a separate significant problem is addressed. In this situation, the preventive medicine E/M code would be billed, as well as, a problem oriented E/M code (with a 25 modifier) for the significant problem.