Pediatric Coding Alert
Office Visit Versus Preventive Medicine Service
Question: Date: 5/11/09 Age: 7 days Some nursing issues HT: 18 in Wt 6 lbs, 5 Bm + urine normal HCM: 13 ¼ in PE: Alert min jaundice sym hands/neck + RR AF/PF flat no bruit TMs C +M n/th 0 clear chest cor T š abd soft NT NM umb att pulse OK nl female genitalia neuro intact I: feeding issue not up to BW P: disc feeding R: 1 week + 2 mo New Jersey Subscriber Answer: This is an office visit (99201-99215). When weighing whether an encounter is a preventive service or a problem-oriented visit, mind these items: 1. The existence of a chief complaint signals a problem-focused visit, rather than a preventive medicine service. The mom brings the baby in for nursing issues, not for an initial or periodic well check. 2. The physician is seeing the newborn for a problem: the mom comes in for nursing issues. Diagnoses include feeding difficulties (779.3, Feeding problems in a newborn) and failure to thrive (783.41). Because the encounter is focused on the baby's problem, use 99201-99215. If your pediatrician or group treated the baby in the hospital, use an established patient visit (99212-99215). Otherwise, use a new patient office visit code (99201-99205). Assuming the history is expanded problem focused (brief HPI, extended ROS, complete PFSH), the medical decision making is low complexity (limited data, limited diagnoses, and moderate risk), and your pediatrician saw the patient in the hospital, you would have a 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a expanded problem focused history; a expanded problem focused examination; medical decision making of low complexity ...). The exam is detailed with seven organ systems (uncounted elements represent body areas). Here's where the physical exam (PE) elements fall: • • • • • • • • • •
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