Pediatric Coding Alert

Question: When parents present with infants for regular health checkups at two, four, and six months, I spend a lot of time counseling and treating colic and GE reflux. Can I report 99212-25 with the ICD-9 code for colic (789.7) or gastroesophageal reflux (530.81) along with 99391 (linked to ICD-9 code v20.2 for a well baby visit)?

Tennessee Subscriber

Answer: According to CPT, you can bill a sick visit (Office or other outpatient services codes 99212-99215) in addition to a previously scheduled preventive medicine service (99381-99385 and 99391-99395) if the presenting problem "is significant enough to require additional work to perform the key components of a problem-oriented E/M service" and modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is attached.

As with any E/M service, the severity of the diagnosis, intensity of medical decision-making and time spent on counseling and coordination of care determine correct coding. Because differentiating the office visit exam from the preventive medicine services visit exam can be problematic, documentation must rest with the history of the present illness and the medical decision-making connected with that illness; or with time-based coding, when counseling/coordinating care constitute more than 50 percent of the face-to-face visit in the outpatient setting.