Pediatric Coding Alert

Reader Question:

No New Code Describes Paperwork

Question: I’ve heard that CPT® has a new code for reviewing records separate from an appointment. Is this true? If so, what do we need to know before reporting it?

Vermont Subscriber

Answer: CPT® 2013 doesn’t include new codes for records review, but already has three codes in place for those situations. The most helpful option for pediatricians for extensive record review is 99358 (Prolonged evaluation and management service before and/or after direct [face-to-face] patient care; first hour). Code 99358 applies to non face-to- face services of 30 to 75 minutes. Be sure to associated and bill code 99358 with a face-to-face associated E/M visit. Careful, complete documentation of time spent is critical.

In the evaluation of E/M visit, there are pre-, intra-, and post-service work components that are valued. Pre-service work includes standard record review.

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