Pediatric Coding Alert
Leg Pain at Well Check
Washington Subscriber
Answer: Because the pediatrician evaluated a significant, separately identifiable problem in addition to performing the preventive medicine service, you should report both the problem-related and the well checkup portions separately. For the established patient well child check, assign 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... early childhood [age 1 through 4 years]) with V20.2 (Routine infant or child health check).
Report the appropriate-level office visit code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) based on the history, examination and medical decision-making that the pediatrician documents for the leg-pain portion.
To designate that the problem E/M is significant and separate from the well check, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 9921x.
In box 21 of the CMS-1500 claim form, you should report V20.2 as the primary diagnosis to support 99392 and two additional ICD-9 codes to indicate the necessity for 9921x-25. For the chief complaint of lower leg pain, list 729.5 (Pain in limb) in the secondary diagnosis position. To explain the cause of injury, use a supplemental E code --E880.9 (Fall on or from stairs or steps; other stairs or steps)--as "dx 3."
Remember: Make sure you separate documentation for both the preventive medicine service and the problem-related (leg pain) visit. If the insurer denies one of the E/M services, use the duel documentation and the distinct diagnoses to support the appeal.
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