Pediatric Coding Alert

Question: A pediatrician re-examines a child who failed an initial hearing screen and finds no hearing loss. Which CPT and ICD-9 code(s) should I use for the exam and test to differentiate the encounter from the preventive-medicine hearing screen visit?

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Answer: You should link 388.40 (Abnormal auditory perception, unspecified) to the service (99212-99215-25, Office or other outpatient visit for the evaluation and management of an established patient; significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service; some payers may not require modifier -25 on the office visit code) and diagnostic test (92552, Pure tone audiometry [threshold]; air only). Without a definitive hearing-loss diagnosis, you should report the symptom - hearing-loss complaint - that prompted the visit.
 
For the hearing test that the pediatrician performed at this second encounter, assign 92552. Because the patient failed the initial hearing screening, the pediatrician would perform the more extensive threshold test to identify hearing-loss specifics.
 
You should also report an office visit (99212-99215) if the pediatrician performed a history, examination and medical decision-making prior to retesting the child's hearing. Because the pediatrician evaluates the child for an illness, use the appropriate-level sick patient office visit code, not a well visit code (99381-99397, preventive medicine services).
 
To indicate that the evaluation is a significant, separately identifiable service from the diagnostic test, append modifier -25 to 99212-99215.
 
If you submit the re-examination encounter as 92552, 99212-99215-25 with 388.40, the payer shouldn't consider the service duplicative of the initial failed screening.
 
You should have reported the preventive medicine service with 99381-99383 (Initial comprehensive preventive medicine evaluation and management of an individual ...) or 99391-99393 (Periodic comprehensive preventive medicine re-evaluation and management of an individual ...) linked to V20.2 (Routine infant or child health check).
 
Depending on whether the pediatrician performed a pure tone (92551, Screening test, pure tone, air only) or threshold (92552) test at the initial screening, you should have submitted 92551-92552 with V72.1 (Special investigations and examinations; examination of ears and hearing). Some payers alternatively require V20.2 with hearing screenings.