Pediatric Coding Alert

Question: What is the proper CPT Code for a routine adolescent pelvic and breast exam? For the ICD-9 code, I used V72.3.

Maine Subscriber Answer: When the pediatrician performs the pelvic and breast exam independently from the annual exam, you should use an office visit code (99201-99215, Office visit for the evaluation and management of a new or established patient ...). In this case, the well diagnosis (V72.3, Special investigations and examinations; gynecological examination) will contradict the sick visit. Therefore, many insurers may deny the E/M service and include the pelvic and breast exam in the patient's annual preventive medicine service (99381-99397). If your pediatrician did provide the pelvic and breast exam at the time of the preventive medicine service, you still couldn't separately report the gynecological examination.

The alternative is to see if your carriers allow using HCPCS codes S0610 (Annual gynecological examination; new patient) and S0612 (... established patient) for the pelvic exam. For instance, Blue Cross Blue Shield of Michigan allows these codes.