tci E/M Coding Alert - 2022 Issue Q4

Reader Question: Don’t Use This Modifier in This Preventive Exam Scenario

Question: Our pediatrician saw an existing 7-week-old patient for a routine checkup with immunizations. During the exam, the physician noticed diaper rash forming. She recommended a couple of over-the-counter creams, advised immediate adminis­tration, and offered additional treatment advice. The doctor then proceeded to administer the vaccines. I understand the vaccine codes, but how would I correctly code the exam and diaper rash? Does this call for modifier 25? New Hampshire Subscriber Answer: For the preventive exam, use 99391 (Periodic comprehensive preventive medicine reevaluation and management… infant (age younger than 1 year)). The diaper rash is a separate problem...

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