Internal Medicine Coding Alert

Published on Fri Jul 26, 2013 PDF

Hint: Appropriate ICD-9 codes will help a robust claim

When your internal medicine specialist sees a newborn child following discharge from the hospital, you’ll need to consider patient status, timing of the visit, and any medical conditions from which the child is suffering to determine whether to report the visit with a “well visit” or a “problem-oriented visit” code.

Consider Timing to Clue in on Purpose of Visit

If your internist is seeing the child two weeks after hospital discharge, he is most likely seeing the child for a “well visit.” In this case, you’ll have to report the most appropriate code depending on the patient status. So, you’ll report the visit 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]) or with 99391 (Periodic comprehensive preventive medicine reevaluation and management…established patient; infant [age younger than 1 year]) depending on if your internist is seeing the child for the first time or has evaluated the child before.

If your internist is seeing the patient earlier than two weeks after hospital discharge, it is more likely that he is evaluating the child for some medical issues. In such a case, you cannot report a well visit and should consider the session as problem-oriented and report it with an appropriate E/M code.

Coder tip: You can also look at the patient notes to get clues on whether to report a “well visit” or a “problem-oriented visit.” If you see in the documentation that your internal medicine specialist made notes regarding the child’s weight, height, immunization status, and development stages, you can probably safely report a well-visit using 99381/ 99391. Instead, if you see documentation mentioning weight loss, feeding problems, colic, jaundice and such, you’ll have to report a problem-oriented visit.

Determine Patient Status to Report Appropriate E/M Code

If your internist is seeing the child for a medical issue, you’ll have to report with an appropriate E/M code. To arrive at the correct E/M code to report for the session, you’ll have to arrive at whether to report an established patient code or a new patient visit code.

In case your internist or any other physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice has provided a professional service to the child within the past three years, you’ll have to report an established patient code for the problem-oriented visit. So, in such a scenario, you’ll choose from the code range 99212-99215 (Office or other outpatient visit for the evaluation and management of an established patient…). If the child is being evaluated for the first time by your physician and no other physician/qualified health care professional of the exact same specialty and subspecialty in your practice has provided a professional service to the child previously, you’ll have to report an appropriate new patient code from the range 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient…), depending on the other factors (e.g. history, examination, and medical decision making) used to determine the level of the code. “In either case, CPT defines a ‘professional service’ as a face-to-face service with its own CPT code,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Support E/M Code With Diagnosis Codes

When your physician is evaluating a newborn for a medical issue or following up on a previously encountered medical problem, you’ll have to support the E/M code that you are reporting for the visit with diagnosis codes that tell the payer why your clinician was seeing the patient. Your documentation will not be complete and the payer might deny payments if the E/M code that you’re reporting is not supported by the appropriate diagnosis codes.

For example, if your physician is evaluating the child for feeding problems, you’ll have to report the diagnosis code, 779.31 (Feeding problems in newborn) to the E/M code that you’re reporting for the session.

Caveat: In case the medical issue for which your internal medicine physician is seeing the patient has resolved since the previous encounter, you should report a diagnosis that reflects the follow-up nature of the encounter. For instance, imagine that, during a hospital visit, your physician suspected the child to be suffering from jaundice and wanted to review the child after discharge. In the subsequent session in the office, he finds no jaundice.In that case, you’ll report V67.9 (Unspecified follow-up examination).

“Do not report 774.6 (Unspecified fetal and neonatal jaundice) as the diagnosis code to support the E/M code you’re reporting for the session, because it implies that the child still has jaundice,” advises Moore. “ICD-9 coding guidelines advise not coding diagnoses considered to be ‘probable,’ ‘suspected,’ ‘questionable,’ ‘rule out,’ or ‘working’ diagnoses,” Moore notes.

In such a scenario, an alternative is to use the V code, V29.8 (Observation and evaluation of newborns and infants for suspected condition not found; Observation for other specified suspected conditions) that lets the payer know that your physician evaluated the infant for a possible condition, which was not found upon examination.

Add V Code to Well Visit

When your physician sees the infant for a well-visit, don’t forget to use the V code, V20.2 (Routine infant or child health check) along with 99381/ 99391. You should not use V20.2 if the purpose of the visit is problem-oriented, as the payer will deny your claim. Reserve the use of this V code for a preventive visit when the child is not suffering from any kind of medical issues.