The patient in the You Code It! scenario presented with a request for human papillomavirus (HPV) immunization and without complaint of a problem. Although some history and constitutional examination were documented by the pediatrician, a significant, separately identifiable office or other outpatient evaluation and management (E/M) service (99201–99205) to address a problem is not supported. An age- and gender-appropriate preventive medicine E/M service was delayed at the father’s request. However, the pediatrician, with patient/caregiver consent, provided 15 minutes of preventive medicine counseling in addition to counseling about the HPV vaccine. Unfortunately, the preventive medicine counseling codes do not differentiate between new and established patients. In addition, when the patient returns the next time, only an established patient E/M service code may be reported.

The pediatrician documented diagnoses of

Diagnosis codes include

Procedure codes include

The provided vaccine (9vHPV) and provided counseling by the physician support codes 90460 and...

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