Primary Care Coding Alert

Question: When parents present with infants for regular health checkups at two, four, and six months, our physician spends a lot of time counseling and treating colic and GE reflux. Can we report 99212-25 with the ICD-9 code for colic (789.7) or gastroesophageal reflux (530.81) along with 99391 (linked to ICD-9 code V20.2 for a well baby visit)?

Tennessee Subscriber

Answer: According to CPT®, you can bill a sick visit (Office or other outpatient services codes 99212-99215) in addition to a previously scheduled preventive medicine service (99381-99387 and 99391-99397) if the presenting problem "is significant enough to require additional work to perform the key components of a problem-oriented E/M service" and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached to the problem-oriented E/M code.

As with any problem-oriented E/M service, the key components of history, exam, and medical decision-making will determine correct coding of the problem-oriented code in this situation, unless you are coding based on time because counseling/coordinating care constituted more than 50 percent of the face-to-face visit. Because differentiating the problem-oriented history and exam from the preventive medicine services history and exam can be problematic, separate documentation of both services may be helpful. The history of the present illness (HPI) and medical decision-making connected with the illness will further distinguish the two services, since preventive visits do not involve either one.