EM Coding Alert

Hint: POS may not affect ‘new’ patient status.

Compare your knowledge of preventive medicine evaluation and management (E/M) service coding to what experts would do.

These two scenarios present situations where coders would need to evaluate what constitutes an abnormal finding in a preventive E/M encounter, and how to report the encounter on the whole.

Scenario 1: Your pediatrician examines and discharges a normal newborn from the hospital. A week later, the newborn presents for their first preventive medicine service at your practice. The pediatrician performs a routine post-discharge exam, but notices the baby has an umbilical granuloma, which the pediatrician treats using a topical application of concentrated silver nitrate solution. What CPT^® and ICD-10 codes would you assign to this encounter?

Scenario 2: The same child presents for immunizations at seven weeks, and during the exam, the pediatrician detects the very mild beginning stage of a diaper rash. The pediatrician tells the parent to use over-the-counter barrier protection and leave the baby undiapered to air out after each diaper change. The pediatrician then immunizes the child with diphtheria, tetanus, pertussis, type B influenza, polio, hepatitis B, pneumonia, and rotavirus vaccines, and counsels the mother about the vaccines. Which CPT^® and ICD-10 codes would you assign to this encounter?

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