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Pediatric Coding Alert

You Be the Coder:

Office Visit Versus Preventive Medicine Service

Published on Fri Aug 28, 2009

Question: A pediatrician submitted the following chart note, which appears as written (no grammar corrections, abbreviations spelled out), but deciphered below. A history form was also completed including taking a full history of the newborn's hospital stay, family history, and problem list ). Should I code it as an office visit or a preventive medicine service? Date: 5/11/09 Age: 7 days Some nursing issues HT: 18 in Wt 6 lbs, 5 Bm + urine normal HCM: 13 ¼ in PE: Alert min jaundice sym hands/neck + RR AF/PF flat no bruit TMs C +M n/th 0 clear chest cor T š abd soft NT NM umb att pulse OK nl female genitalia neuro intact I: feeding issue not up to BW P: disc feeding R: 1 week + 2 mo New Jersey Subscriber Answer: This is an office visit (99201-99215). When weighing whether an encounter is a preventive service or [...]
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