Adding EM Visit / Pediatric Wellness Visit


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I am wondering if I can add an E/M visit in addition to a wellness visit for pediatric care. In addition to the wellness visit, the newborn had neonatal obstruction in additional a clicking hip. DX codes H04.532 and R29.4 respectively. There was a depression screening added for a the mother, CPT code 96161.

I am new to pediatric billing.



True Blue
Beaverton OR
Best answers
The wellness visit for pediatric care is a preventive benefit as is usually an annual visit for the child. Correct coding may allow an E/M visit added to an annual preventive visit if medical necessity supports it, however many insurance carriers have their own policies on what is allowed and what is not allowed with preventive + E/M. The problem in my eyes is when it comes to differentiating the content of the note into preventive and E/M, as you cannot double dip (use same information towards both codes). If the carrier allows both codes, then I would suggest carving out anything that can be used towards the preventive portion, and then whatever you have towards the E/M level without crossing over.

My previous practice had a policy which suggested that providers only chose the code they spent 50% or more time on. In other words, if the provider spent 25 minutes from the 30 minute visit on preventive concerns, then bill the preventive code. This was only for simplicity and to avoid too many denials and is not a perfect practice.

To your note, you should be able to bill both codes if documentation is solid enough to support an E/M on top of the wellness visit, as the neonatal obstruction could be a significant enough problem to warrant an E/M for that visit. Again, check that patient's insurance policy first and go from there.

Hope that helps!