elee6677
New
Pediatric patient seen for 99393 e/m preventative 5-11 years of age. Doctor also performed follow up examination for an ear infection. Can he bill in addition to the 99393?-
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Wiki In addition to 99393??? help
- Thread starter elee6677
- Start date
Pediatric patient seen for 99393 e/m preventative 5-11 years of age. Doctor also performed follow up examination for an ear infection. Can he bill in addition to the 99393?
hewitt
Expert
Absolutely! This is often done in Peds. The AMA CPT Assistant says, "The comprehensive history obtained as part of the preventive medicine E/M service is not problem-oriented, and does not involve a chief complaint or present illness. It does, however, include a comprehensive system review and comprehensive or interval past, family, and social history, as well as a comprehensive assessment/history of pertinent risk factors." You have to make sure there is a "significant, separately identifiable" problem. Though not necessarily required, it is better to document both separately in the medical note. 