Pediatric Coding Alert

Question: My pediatrician has just seen an infant for a wellness visit. The infant was born premature with a gestational age of 28 weeks and is now 4 months old. In her notes, the pediatrician wrote that she spent 15 minutes coordinating care with the patients and counseling them about the differences between an infant who has gone to term and one who has not and what should be expected of their child under the circumstances. The pediatrician believes that we should charge for the counseling separately as it went beyond what would normally be expected for a wellness visit of this kind. Can we charge for an additional evaluation and management (E/M) service under these circumstances, and if so, can we use P07.31 for the primary diagnosis?

New Jersey Subscriber

Answer: The guidelines for the preventive medicine service codes stipulate that they “include counseling/anticipatory guidance/risk factor reduction interventions which are provided at the time of the initial or periodic comprehensive preventive medicine examination.”

This means the counseling your pediatrician describes is included as part of the services associated with 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)). So, you cannot charge separately for this part of the service.

>Had the counseling occurred separately from the well visit — for example, if it occurred on its own or in conjunction with a sick visit — you could have charged for it using 99401 (Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes) using time for documentation. In this case, you could use P07.31 (Preterm newborn, gestational age 28 completed weeks) as the primary diagnosis providing the child’s gestational age was between 28 weeks, 0 days through 28 weeks, 6 days. Per ICD-10 guideline 1.C.16.e, the P07 (Disorders of newborn related to short gestation and low birth weight, not elsewhere classified) codes “are for use for a child or adult who was premature … and this is affecting the patient’s current health status.” So, they can be used at any time when the patient encounters health and psychological problems, such as hearing and vision problems or developmental delays, associated with premature birth.