Primary Care Coding Alert

Question: An established 2-year-old patient presented for a well child checkup. The patient's mother claimed the child had been walking with a limp and complaining of lower leg pain for the past three days after falling from the second bunk-bed step. The FP focused on further (extensive) evaluation of these symptoms and indicated a plan of x-ray and possible referral to orthopedics. The FP then completed the well child exam. How should I report the encounter?

Washington Subscriber

Answer: Because the FP 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 99212 or 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 FP 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 have 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 dual documentation and the distinct diagnoses to support the appeal.