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Sick Visit/physicals/ Vaccinations

  1. #1
    Default Sick Visit/physicals/ Vaccinations
    Medical Coding Books
    Hello, I am still very new at coding Peds and I have a question.
    A new patient child walks in and is very behind on vaccines and his physicals. Doctor performs the comprehensive exam and the physical per the American Academy of Pedatricians guidelines. However, the child is sick so he is unable to give the child the vaccinations. He prescribes an antibiotic and tells the mother to bring the child back in 1 wk. Should I code the first visit as new patient e/m as sick and in one week a physical with the vaccinations? Or the first visit a physical and the second with an e/m and vaccinations? He is performing the physical on both days. On the first day the diagnosis well check or routine physical is left out and on the second visit he may be working to hard. I think I should code the first visit a physical and the second visit with the e/m along with the vaccinations and just advise the doctor to write well check and routine for the first visit. According to the American Academy of Pediatrics the doctor must perform the physical if the child is behind. But some cases the mother does not even bring the child back in one week for the vaccinations. Does anyone disagree about how I am thinking to code this scenario and think I should not advise the doctor to list the diagnosis well check. I am thinking to cover himself with the AAP, he should write the dx routine well check or routine physical in case the mother does not comply. If this diagnosis is left out is it still considered a physical?? Would like some input and would like to know how other offices are coding this scenario.

    Thanks
    Leilani, CPC
    Last edited by leilani; 04-18-2008 at 03:52 PM.

  2. #2
    Smile
    Quote Originally Posted by leilani View Post
    Hello, I am still very new at coding Peds and I have a question.
    A new patient child walks in and is very behind on vaccines and his physicals. Doctor performs the comprehensive exam and the physical per the American Academy of Pedatricians guidelines. However, the child is sick so he is unable to give the child the vaccinations. He prescribes an antibiotic and tells the mother to bring the child back in 1 wk. Should I code the first visit as new patient e/m as sick and in one week a physical with the vaccinations? Or the first visit a physical and the second with an e/m and vaccinations? He is performing the physical on both days. On the first day the diagnosis well check or routine physical is left out and on the second visit he may be working to hard. I think I should code the first visit a physical and the second visit with the e/m along with the vaccinations and just advise the doctor to write well check and routine for the first visit. According to the American Academy of Pediatrics the doctor must perform the physical if the child is behind. But some cases the mother does not even bring the child back in one week for the vaccinations. Does anyone disagree about how I am thinking to code this scenario and think I should not advise the doctor to list the diagnosis well check. I am thinking to cover himself with the AAP, he should write the dx routine well check or routine physical in case the mother does not comply. If this diagnosis is left out is it still considered a physical?? Would like some input and would like to know how other offices are coding this scenario.

    Thanks
    Leilani, CPC

    You can code this as:

    FIRST VISIT

    Dx's -- 1) sick visit dx
    2) V20.2

    procedure codes-- 1) 9920_ plus modifier 25 (dx code 1)
    2) 9938_ (dx code 2)

    SECOND VISIT

    Dx's --1) V67.51
    2) V20.2
    3) Vaccine code
    4) Immun Adm code (V05.9)

    procedure codes-- 1) 9921_ plus modifier 25 (dx 1)
    2) 9939_ (dx code 2,3)
    3) vaccine code (dx 3)
    4) Immun adm code (dx 4)

    wow......hope this helps.....

    YTH, CPC

  3. #3
    Default
    Thank you for your help. Would you code the first sick visit and a physical if the doctor does not state well child check or routine for his diagnosis? Like I mentioned above per the American Academy of Peds, he needs to do the physical if the child is behind. In addition, if the child is a new patient he is covering all the key elements and doing a comprehensive physical exam because I see it in notes, but the dx is left out. So would anyone suggest I advise the doctor to write well check or routine along with his sick visit dx on the first visit in case the mother does not bring the child back in one week for vaccinations? The doctor thinks he will just see the patient in one week, so he will write it when he vaccinates the child, but most of the time the mother does not bring the child back. I think he should because he needs to cover himself as a Peds doctor, but I just need know if it needs to have the dx well check in order to charge the physcial. Any input anyone?

    Thanks
    Leilani, CPC

  4. #4
    Smile
    Quote Originally Posted by leilani View Post
    Thank you for your help. Would you code the first sick visit and a physical if the doctor does not state well child check or routine for his diagnosis? Like I mentioned above per the American Academy of Peds, he needs to do the physical if the child is behind. In addition, if the child is a new patient he is covering all the key elements and doing a comprehensive physical exam because I see it in notes, but the dx is left out. So would anyone suggest I advise the doctor to write well check or routine along with his sick visit dx on the first visit in case the mother does not bring the child back in one week for vaccinations? The doctor thinks he will just see the patient in one week, so he will write it when he vaccinates the child, but most of the time the mother does not bring the child back. I think he should because he needs to cover himself as a Peds doctor, but I just need know if it needs to have the dx well check in order to charge the physcial. Any input anyone?

    Thanks
    Leilani, CPC
    I would "YES" he needs to add dx....

  5. #5
    Default
    Thank you. I will educate the doctor.

    Leilani, CPC

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