Pediatric Coding Alert

Question: An established 2-year-old patient presented for a well child checkup. The patient's mother claimed the child had been walking with a limp and complaining of lower leg pain for the past three days after falling from the second bunk-bed step. The pediatrician focused on further (extensive) evaluation of these symptoms and indicated a plan of x-ray and possible referral to orthopedics. The well child exam was completed. How should I report the encounter?


Washington Subscriber


Answer: Because the pediatrician evaluated a significant, separately identifiable problem in addition to performing the preventive medicine service, you should report both the problem-related and the well checkup portions separately. For the established patient well child check, assign 99392 (Periodic comprehensive preventive medicine reevaluation and management of an individual ... early childhood [age 1 through 4 years]) with V20.2 (Routine infant or child health check).

Report the appropriate-level office visit code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) based on the history, examination and medical decision-making that the pediatrician documents for the leg-pain portion.

To designate that the problem E/M is significant and separate from the well check, append modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to 9921x.

In box 21 of the CMS-1500 claim form, you should report V20.2 as the primary diagnosis to support 99392 and two additional ICD-9 codes to indicate the necessity for 9921x-25. For the chief complaint of lower leg pain, list 729.5 (Pain in limb) in the secondary diagnosis position. To explain the cause of injury, use a supplemental E code --E880.9 (Fall on or from stairs or steps; other stairs or steps)--as "dx 3."

Remember: Make sure you separate documentation for both the preventive medicine service and the problem-related (leg pain) visit. If the insurer denies one of the E/M services, use the duel documentation and the distinct diagnoses to support the appeal.