Pediatric Coding Alert

You Be The Coder:

Coding a Sick/Well-Check Visit

Published on Tue Apr 27, 2004

Question: A parent schedules an appointment for a child's 12-month checkup. Our pediatrician examines the child and finds congestion, nasal drainage and rash. He orders a rapid strep, which is negative. He recommends that the mother "observe for now" and "follow up as needed." He then performs the checkup, including addressing diet, age-specific growth, etc. He also gives the parent literature about immunizations, and addresses her concerns and administers the vaccinations. What is the correct service coding for this dual visit? Should I use modifiers, and if so why?

Texas Subscriber

Answer: You should bill for each E/M service. For the preventive medicine service, you should report CPT 99392 (Periodic comprehensive preventive medicine re-evaluation and management of an individual including an age- and gender-appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization[s], laboratory/diagnostic procedures, established patient; early childhood [age 1 through 4 years]). You should choose the appropriate-level office visit (99212-99215, Office visit for the evaluation and management of an established patient ...) based on the pediatrician's problem-related documentation. To indicate that the sick visit is a separately identifiable E/M service from the checkup, you should append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to 9921x.

You should link each E/M to the related diagnosis. Use V20.2 (Routine infant or child health check) with 99392. Link 9921x-25 to the sick diagnosis, such as nasal congestion (460, Acute nasopharyngitis) and/or rash (782.1, Rash and other nonspecific skin eruption).

Some payers, however, may not pay for two same-day E/M services. Check your contracts and see whether the patient's insurer considers a second E/M a noncovered or bundled service. For a noncovered service, you may bill the patient. You will have to write off a bundled service. To avoid losing payment or charging the parent, you could suggest that the mother reschedule the checkup.