Wiki Well visit & other problems presented

[chayawieder]

if child comes for a well visit, and during the visit the mother talks about a problem and the doctor handles the problem - he also finishes the well visit (gives vaccines etc). How would you code?

it may be a basic question but I just started working in peds. thanks

 

[lavanyamohan]

Hi,
It depends on the problem handled.
For instance, if this is nebulizer treatment, may not be considered separately.
But pneumococcal vaccinations may be reported separately along with the well visit preventive codes.

Regards,
LMohan

 

[shenikpinder]

Well visit and other problems presented

If the separate issue/problem is documented separately and is addressed, assessed and/or treated and can be identified as a separately identifiable issue, then I would code the wellness, then the appropriate level E&M with a -25 mod and any other service that is performed to include the vaccines.

Ex: If the pt had a wellness exam, vaccines and was having breathing issues that required assessing and a neb treatment, I would code it as:

wellness E&M-25 mod
problem E&M-25 mod
Neb administration
Medication administered in neb
Vaccine admin codes
Corresponding vaccines

Thoughts?