Wiki Well Child Visits.


True Blue
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If the documentation for a well child visit is all there. But also a quick notation at the bottom of the progress note. Like this.

Assement says: Well visit, Otitis Media

Plan: Anticipatory Guidance
Prescription Amoxicillin for 7 to 10 days.

Would and could you squeeze an an E/M 99212 for the otitis media.

Meaning your visit would look like this.

99392. V20.2

Let me know your input.

thank you
Per the CPT guidelines, if an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventative medicine E/M service and if the problem is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code should also be reported with -25 attached in addition to the preventative E/M code.

There needs to be separate documentation to show that the OM was addressed. All you indicate here is that the physician documented the OM at the bottom of the progress note. In order to bill the 99212 you would have to have 2 out of the 3 elements to meet for an established patient E/M. Do you have any HPI related to the OM? Do you have any documentation of an exam related to the OM? If all you have as you say is the notation at the bottom of the OM, then you can't bill the 99212. There needs to be separate documentation showing the key elements (history, exam, MDM) to justify the 99212-25. Hope this helps.