Pediatric Coding Alert
You Be the Coder:
Default to E/M for Toilet Training Issues
Published on Thu Dec 12, 2013
Question: Which CPT code would you recommend using when the pediatrician evaluates a three-year-old who refuses to stool in the toilet? There are no other physical concerns.
Answer: Assuming you’re seeing the patient outside of a regularly-scheduled well child visit, you’ll report the appropriate E/M code (99201-99215) for the visit. If you spend a significant amount of time counseling the parents on the issue, you might be able to select the E/M code based on time spent, as long as you document the total time as well as the time spent counseling the family. This can be reported with or without the child present.
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Pediatric Coding Alert
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