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Question: Our pediatrician saw a 6-day-old baby for the first time and diagnosed an umbilical granuloma. The physician treated the patient with a concentrated silver nitrate solution, applied topically. How should I code this encounter?

Kansas Subscriber

Answer: Since the baby is receiving services from the pediatrician and practice for the first time, you鈥檇 use CPT^庐 code 99381 (Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)) with ICD-10-CM code Z00.110 (Health examination for newborn under 8 days old).

If the pediatrician has seen the patient before, you鈥檇 use 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)).  

While you may first think of using Z00.121 (Encounter for routine child health examination with abnormal findings), the Excludes1 guidance for the code points to Z00.11- (Newborn health examination) because the newborn exam code takes precedent over the abnormal findings code.

You鈥檒l use P83.81 for the umbilical granuloma and 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)) for the cauterization via the concentrated silver nitrate solution.

You may be justified in billing an office/outpatient evaluation and management (E/M) service in addition to the preventive E/M of the scheduled exam, in which case you鈥檇 append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) to the office/outpatient E/M 鈥渢o indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service,鈥� per CPT^庐 guidelines.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC