Pediatric Coding Alert

Question: I code for a pediatrician that wants to add an additional evaluation and management (E/M) encounter to almost every well-child visit (WCV).

Here are two examples. First, a child came in for a WCV and told the pediatrician that she had fallen and hurt her wrist. The doctor examined the wrist, notes that it is tender, and orders X-rays. Second, a male patient came in for a WCV, which the pediatrician combined with an attention deficit hyperactivity disorder check-up. The pediatrician noted that the child was doing well and that there was no need to change the child’s meds at this time.

So, do either of these qualify for a separate problem visit with modifier 25 attached?

Arkansas Subscriber

Answer: While it is permissible to report a WCV using the appropriate code from 99381-99396 (Initial/periodic comprehensive preventive medicine evaluation and management of an individual …) and an appropriate E/M from 99201-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) with 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) appended to the E/M, only one of the scenarios you outline here fits the criteria for doing so.

According to the American Academy of Pediatrics (AAP) FAQ for Coding Encounters in ICD‐10‐CM, “just because an abnormality is discovered during the routine well child exam does not mean that a separate E/M service should or can be reported. If the criteria are met for reporting a significant and separately identifiable E/M service in addition to the preventive medicine service, then yes one should be reported. However, simply reporting the Z00.121 [Encounter for routine child health examination with abnormal findings] does not automatically equate to a separate E/M service” (Source: www.aap.org/en-us/Documents/coding_faq_coding_encounters_icd_10.pdf).

Those criteria, defined by CPT^®, state that “an insignificant or trivial problem/abnormality that is encountered in the process of performing the preventive medicine evaluation and management service and which does not require additional work and the performance of the key components of a problem-oriented E/M service should not be reported.”

So, as there was no exam, history, or medical decision making (MDM) involved in the second encounter, the encounter has not met the criteria for a significant, separate E/M.

As for the first encounter, you could possibly make a case that the pediatrician’s problem-focused examination of the patient’s wrist, and the minimal level of MDM involved in ordering the X-ray, do meet the “2 of 3 components” criteria to justify a significant, separate low-level E/M (such as a 99212) for an established patient. However, to make that case, your pediatrician’s documentation will have to support this.

Lastly, neither of the conditions you mention in both of these scenarios rise to the level of abnormal findings. They are both presenting complaints; consequently, you cannot use Z00.121 on the preventive E/M. Instead, assuming the children in question are over 28 days old, you should use Z00.129 (Encounter for routine child health examination without abnormal findings), though if the X-ray in the first encounter demonstrated a fracture requiring further treatment, that would justify use of Z00.121.