Pediatric Coding Alert

Question: Is it double-dipping to bill a new preventive-medicine services visit and a new office visit on the same day?

Anonymous NM subscriber

Answer: If you see a new child for a scheduled preventive-medicine services visit (99381-99385) and that child turns out to be sick, should you use a new-patient office visit code (99201-99205) or an established-patient office visit code (99211-99215)? Most billers would probably say new. After all, the child is new for that date of service. However, the answer isnt that simple. In fact, the answer is that you should not use the new patient codes for both services.

And this makes sense, if you consider that the new codes pay considerably more than the established codes. This is to reimburse the physician for the extra work involved with the history and physical of a new patient. Therefore, if you get reimbursed for one new code on a given date for a given patient, you shouldnt need to perform all those new services again on the same day. If you do, you are indeed double-dipping.

Note: See last months issue of PCA for information about how to get paid for well- and sick-visits on the same day. The information appears in, Modifier -25: How to Get Paid for Well and Sick Visits on the Same Day, on page 60.)