During a yearly physical, a 15-year-old boy is treated for a urinary tract infection after a history and exam and U/A. Which CPT codes are reported?

During a yearly physical, a 15-year-old boy is treated for a urinary tract infection after a history and exam and U/A. Which CPT codes are reported?

• A. 99394
• B. 99213
• C. 99213, 99394-25
• D. 99213-25, 99394

Answer: (D)

The key idea is reporting two distinct services on the same visit: a preventive Well-Care exam and a separate problem-focused E/M service for the urinary tract infection. When both occur in one encounter, you bill the preventive service and also bill the problem-oriented E/M, using modifier -25 on the E/M code to show it’s a separate, independently identifiable service. For this 15-year-old, the annual physical fits the preventive category for an established patient aged 12–17, which is code 99394. The urinary tract infection treated during the same visit is a separate problem that requires an E/M assessment, and 99213 is an appropriate level for an established patient with a minor to moderate problem like a UTI. Because these are two distinct services, you report both: 99213-25 for the problem-focused visit and 99394 for the preventive visit. It wouldn’t be correct to append -25 to the preventive code, since modifier -25 is used with evaluation and management codes (99213, etc.), not with preventive codes. Also, reporting only one code would miss either the preventive service or the problem-focused visit, which is why the combination shown is needed.

The key idea is reporting two distinct services on the same visit: a preventive Well-Care exam and a separate problem-focused E/M service for the urinary tract infection. When both occur in one encounter, you bill the preventive service and also bill the problem-oriented E/M, using modifier -25 on the E/M code to show it’s a separate, independently identifiable service.

For this 15-year-old, the annual physical fits the preventive category for an established patient aged 12–17, which is code 99394. The urinary tract infection treated during the same visit is a separate problem that requires an E/M assessment, and 99213 is an appropriate level for an established patient with a minor to moderate problem like a UTI. Because these are two distinct services, you report both: 99213-25 for the problem-focused visit and 99394 for the preventive visit.

It wouldn’t be correct to append -25 to the preventive code, since modifier -25 is used with evaluation and management codes (99213, etc.), not with preventive codes. Also, reporting only one code would miss either the preventive service or the problem-focused visit, which is why the combination shown is needed.