Adding an Appropriate Sick Visit Code for Select Well Visits

The selection of the appropriate E&M code is dependent upon time and/or complexity. This article provides an analysis on the addition of appropriate sick visit codes (e.g. 99212-99215) for when a child is present for a well visit. The determination of adding a sick visit code during a well visit is decided per the provider’s discretion. Due to a gap in understanding, many pediatric providers tend to under code during a well visit.

There are three primary factors that pediatric providers need to consider during a well visit:

1. The Patient has a Chronic Condition or Problem
2. The Patient and/or Parent Confirms Current or Previous ‘Flare Up’ of Condition or Problem Since Previous Visit
3. The Provider Determines That a Problem Needs Either Evaluation or Treatment

If all three of the above considerations are true then, typically, the provider should add the appropriate E&M code to the well visit. Prior to reviewing the selection of an appropriate E&M code, allow us to take a look at each of these three considerations in greater detail.

• The Patient Has a Chronic Condition or Problem:   A chronic condition or problem includes patients with ADHD, anxiety, asthma, allergies, depression, developmental delays, respiratory disease, skin conditions, amongst various other conditions. The condition may be from a previous visit, or discovered during the well visit discussion.

• The Patient and/or Parent Confirms Current or Previous ‘Flare Up’ of Condition or Problem Since Previous Visit

There are two areas to address related to a particular condition –

1. Current/Active Issue – The condition or problem is active and is an issue for the patient. An example of this would be a patient wheezing during the well exam, an indication that they are experiencing an asthma flare-up. The provider would then assess the severity, make any necessary adjustments to the patient’s treatment plan, and document the visit.
2. Issue Since Last Contact w/ Office – If the patient does not have an active condition, the provider should inquire about the number of flare-ups since last contact with the office. If there have been no changes (or issues), a sick visit code should not be added. If the patient expresses that there has been a flare-up since their last engagement with the provider, then the provider should assess the flare-up, determine if there is a need to update/change the treatment plan, document the visit, and then select the appropriate E&M code.

• The Provider Determines That a Problem Needs Either Evaluation or Treatment

1. If the provider assesses OR treats a problem/condition during the well visit, then the provider should capture the assessment OR treatment in the visit notes and select a corresponding E&M code.
2. If the provider determines no issue to be present during the well visit or issue with their chronic condition since the last visit, a sick visit code should not be added.                                                                                 

The summary provided above should help in identifying well visit encounters where providers may add an appropriate sick visit E&M code. The sick visit code selected is based either on the level of Medical Decision Making (MDM) or the total time spent during the visit (discussed in previous articles).  The provider must select the appropriate E&M code(s), since they are present during the well visit and have a greater understanding of the situation/patient.

While we provide benchmarking for practices including the percentage of sick visit E&M codes that were added to the respective well visits, please keep in mind that there are variations from the ‘average’ based on the patient population of the practice and issues that occur during a select time frame. Practices that have patients with a multitude of chronic conditions tend to have more well visits with the addition of sick visit codes than that of the national average, thus an appropriate variation. While the ‘average’ may be considered a good guide for benchmarking/understanding practice performance in this area, it is of greater interest that the provider appropriately identifies the patient’s problem, documents it in their clinical chart, and selects the appropriate E&M code.

Many practices and/or providers receive less than appropriate compensation when the provider(s) does not optimally capture the addition of a sick visit code to a well visit. Additionally, please note that some providers may risk a payor pull back of funds by not appropriately identifying/documenting said diagnostic information in the patient’s clinical chart upon adding a sick visit code.