Pediatric Coding Alert

Question: An established patient presents in the office for an otitis media recheck. The pediatrician spends about 10 minutes reviewing the previous--now resolved--problem, and would have been finished with the visit. However, the mother asks questions about the child's attention deficit disorder (ADD). A discussion on options and risks involved, possibility of medications and other forms of treatment takes about 25 minutes. The patient's visit lasts a total of 35 minutes. What CPT code should I use for the visit?


Florida Subscriber


Answer: The short answer to your question is 99214. If the visit had been comprised of only the otitis media recheck, in which no problems were found, the encounter for a previous problem alone would probably qualify as 99212 or 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...). Choose the level based on the documentation that meets the required elements (two of three key components).

Catch: The discussion that followed the recheck took an additional 25 minutes of time. Because the discussion comprised 50 percent or more of the total face-to-face time of the visit, you should use time as the controlling factor to select the level of service.

A total of 35 face-to-face minutes exceeds the approximate time that CPT designates for a level-four established patient visit (99214, ... physicians typically spend 25 minutes face-to-face with the patient and/or family). Important: The time spent does not meet the time threshold for 99215, which requires 40 minutes

Remember: Documentation of total face-to-face time and time spent counseling is critical. If documentation shows the exact amount of time spent in discussion and what was discussed as you described above, you should report the encounter with 99214.