Pediatric Coding Alert

Question: As part of a patient well check, our pediatrician ordered a urinalysis, which came back abnormal. The child came back in the next day to repeat the test, which came back normal. What codes should I use to document this situation?

Maryland Subscriber

Answer: On the first date of service, you would code for the well-child check using the age-appropriate code from 99381-99395 (Initial/periodic comprehensive preventive medicine evaluation/reevaluation and management of an individual …). Additionally, as the preventive evaluation and management (E/M) uncovered an abnormal finding, you can also bill 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making …) based on the ordered and reviewed test and a self-limited or minor condition that presents a low risk of morbidity from additional diagnostic testing or treatment. You would also 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 99213 to show the office/outpatient E/M service was significant and separate from the preventive service.

Next, you would code for the urinalysis test itself, presumably 81000 (Urinalysis, by dip stick or tablet reagent ... non-automated, with microscopy) or 81002 (... non-automated, without microscopy) if the tests were performed in-house. And you’ll need to add Z00.121 (Encounter for routine child health examination with abnormal findings) to the preventive E/M and an appropriate signs and symptoms code for the condition such as R31.9 (Hematuria, unspecified) or R80 (Proteinuria) depending on the lab test findings.

Typically, in urine rechecks like this on a different date of service, you won’t be able to justify the medical necessity for a significant, separate office/outpatient E/M unless your pediatrician performed one. Instead, you’ll simply use the appropriate urinalysis lab code again for the test along with Z09 (Encounter for follow-up examination after completed treatment for conditions other than malignant neoplasm).