Internal Medicine Coding Alert

You Be the Coder:

Confused About Reporting Incomplete Annual Exam? Here's What to Do

Published on Thu Mar 31, 2016

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Question: A 16-year-old girl presents for a well-child preventive medicine service with a school form that she needs filled out for sports. The nurse takes the patient’s measurements and vitals. Our physician performed a routine history and provides age- appropriate patient education.

But when our clinician tried to perform the physical, the patient refused to be examined. After our physician informed the waiting mother of the incomplete physical, the parent and daughter left the exam room. How should I code the incomplete well-child exam? Our physician spent 15 minutes with the patient.

Illinois Subscriber

Answer: You may report either 99213 or 99401 for the exam with a counseling code, or claim reduced services with the well exam diagnosis.

Because your clinician couldn’t complete the physical, you may not want to code a well exam (99381-99395, Preventive medicine service). You could instead bill the encounter based on the time your physician spent counseling the patient.

You could code the 15 face-to-face counseling minutes with 99401 (Preventive medicine counseling and/or risk factor reduction intervention[s] provided to an individual [separate procedure]; approximately 15 minutes). The encounter meets CPT^®’s requirements for using the counseling and/or risk factor reduction intervention codes (99401-99404). The patient doesn’t have an established illness. Your internal medicine specialist provides the counseling at a separate encounter to promote health and prevent illness.

Some insurers, however, don’t cover preventive medicine counseling codes. In this case, you may want to use the appropriate-level office visit code (99213, Office or other outpatient visit for the evaluation and management of an established patient ...).

Because your internist spends the majority of the encounter on counseling, the visit qualifies for time-based billing. Based on your clinician in your scenario spending 15 minutes face-to-face with the patient, you could assign 99213. CPT^® indicates 99213 typically involves this amount of time.

You should link 99213 or 99401 to a counseling diagnosis. You could assign one of two codes:

Z76.89 - Persons encountering health services in other specified circumstances
Z71.9 - Counseling, unspecified.

Alternative: You may instead want to report the preventive medicine service appended with modifier 52 (Reduced services). The modifier indicates that you provided some of the work a well child visit involves, but due to certain circumstances, you couldn’t provide the full service. Therefore, you are reporting a reduced charge.

If you choose this method, link the well exam code to Z00.129 (Encounter for routine child health examination without abnormal findings).