Code This Periodic Physical With Additional Services
Question: When an existing patient is scheduled for their periodic physical exam, but the pediatrician addresses an additional problem during that exam, does that additional problem require a second evaluation and management (E/M) code? Revenue Cycle Insider Subscriber Answer: The answer to that would depend on what service(s) were additionally rendered during the wellness visit. For instance, if a pediatrician carries out all the typical components of a wellness checkup — including an age-suitable history, examination, counseling/anticipatory guidance/risk factor reduction, and ordering relevant labs or diagnostic procedures — for a 13-year-old patient worried about not having started their menstrual cycle yet, this discussion would probably not necessitate any extra coding. This is because addressing menstruation would be part of that wellness visit already, and the doctor would not likely consider that a developmental delay of any kind, so no further examination or coding would be necessary. For this encounter, you’d simply code the existing patient physical, using a code like 99394 (Periodic comprehensive preventive medicine reevaluation 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, established patient adolescent; (age 12 through 17 years)). On the other hand, let’s say the pediatrician performed all the elements of a standard wellness visit, and then the patient mentioned experiencing muffled hearing in their right ear. When the pediatrician looked in their ears, they noticed significant buildup of wax in the right ear only, but it wasn’t impacted. The pediatrician flushed it out, then had a brief conversation with the patient about their history of wax buildup leading to muffled hearing, whether they were doing anything to control the buildup, and suggestions for how to manage excessive earwax production going forward to avoid future issues. This scenario would require you to report the existing patient physical first using code 99394, because that’s the reason for the encounter. Then you’d need to report the wax removal, about which CPT® guidelines say the following: “For cerumen removal that is not impacted, see E/M service code.” That would mean using the appropriate E/M code from 99391-99397 (Periodic comprehensive preventive medicine reevaluation 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, established patient …). Remember that because the E/M was significant and separately identifiable, you’d append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the E/M if the documentation adequately supported how the E/M service for the earwax was separate from the discussions and evaluations involved in the wellness exam. Lindsey Bush, BA, MA, CPC, Production Editor, AAPC
