Pediatric Coding Alert

Question: A 16-year-old established female patient comes in for her annual checkup. Although she claims that she is not sexually active, she missed her last period. The pediatrician performs a pelvic exam and provides contraceptive counseling. Is the pelvic exam separately reportable from the physical?

North Dakota Subscriber

Answer: In this case, because the pediatrician treats a problem during a well check, you should report both services. For the physical, use the age-specific established patient preventive medicine service: CPT 99394 (Periodic comprehensive preventive medicine reevaluation and management ...; adolescent [age 12 through 17 years]). Normally, 99394, as well as 99395 ( 18-39 years), includes a pelvic exam. But if during the annual checkup the patient has a problem, you should also report a sick-visit code (99212-99214, Office or other outpatient visit for the E/M of an established patient ) appended with modifier    -25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) to indicate a significant, separately identifiable E/M service by the same physician on the same day of service.
 
Some insurers, however, incorrectly reject a second office visit appended with modifier -25, so make sure you link the correct diagnosis to each E/M code. For the well check, report V20.2 (Health supervision of infant or child, routine infant or child health check). Use the problem, dysmenorrhea (625.3), for the sick visit (99212-99214).