Pediatric Coding Alert

Question: If our pediatrician sees an adolescent girl who is not yet sexually active for a routine evaluation and management (E/M) visit, and the provider determines that the girl needs an internal pelvic exam, can we bill for both the E/M visit and the exam, or is the exam considered to be a part of the E/M service?

Arkansas Subscriber

Answer: If you report 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]), an internal pelvic exam is regarded as part of the comprehensive preventive examination per the CPT^® descriptor.

However, if you document either 99213 (Office or other outpatient visit for the evaluation and management of an established patient ... 15 minutes ...) or 99214 (... 25 minutes ...), you can then go on and bill for the gynecological exam using Z01.419 (Encounter for gynecological examination [general] [routine] without abnormal findings) along with other, related tests or screenings, such as a pap smear or a sexually transmitted disease (STD) screening, providing you attach 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.