Pediatric Coding Alert

Question: During a newborn preventive medicine service, the pediatrician addresses the child's goopy eye. Actual documentation reads exactly as follows: Date: 5/18/09 Age: 13 days R eye goopy Ht. Wt. HCM NB F/UP Not every day 6 lb 4 oz Warm cloth to wipe it Sim Adv: eating 2 oz e 3 h BM & urine OK sees & hears PE: Alert vigorous AF/PF flat +RR HEENT φ re wet R eye chest cor abd φ umb attached hips stable φ O/B/G all else well I: doing well mild dacryocystitis P: wt -- 10d Eythro Ophth Oint Safety US hips in June R: 10d & 7wks+ 2 mo Should the pediatrician report an E/M-25 for the eye care? New Jersey Subscriber Answer: "Yes, I could have added 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key [...]