Wiki Circumcision and Preventative visit


West Point, CA
Best answers
Chief complaint: weight check & circumcision
HPI formula feeding, gaining weight, appropriate responses..
Full ROS; negative as per HPI
Exam; comprehensive
Procedure note for the circumcision.
Assessment plan;
patient gaining weight appropriately
continue vitamin d exposure with sunlight
post operative care for circumcision.
Mention of next appointments

Would it be supported to bill for a 'weight check' Z00.111 99391 with the circumcision in the absence of a problem per se? Are weight checks in and of themselves necessary for babies? If a full history and exam are done at a circumcision is that enough for a wellness check if the chief complaint states "weight check and circumcision" ?

Hello baroquecoder,

The documentation you have provided does not seem to support a Preventative visit as it is missing some of the guidelines and information that should be documented to support the Preventative service. Please see the guidelines below and if supported on the actual documentation you have than it would support 99391 modifier 25. If the weight check is in follow-up to a known problem such as a feeding problem, then the visit is not preventive and is reported with the appropriate level of E/M service and related diagnosis.

•Weigh the newborn; assess the newborn’s general health, hydration, and extent of jaundice; identify any new problems; review feeding pattern and technique; and obtain historical evidence of adequate urination and defecation patterns for the newborn.
•Assess quality of mother-baby attachment and details of newborn behavior.
•Reinforce maternal or family education in newborn care, particularly concerning feeding and safety such as breastfeeding, back to sleep, and child safety seats.
•Review the results of outstanding laboratory tests, such as newborn metabolic screens, performed before discharge.
•Perform screening tests in accordance with state regulations and other tests that are clinically indicated, such as bilirubin measurement.
•Verify the plan for health care maintenance, including a method for obtaining emergency services, preventive care and immunizations, periodic evaluations and physical examinations, and necessary screenings.
•Assess for parental well-being, including postpartum depression in the mother.