Orthopedic Coding Alert

You may be able to substitute notes to justify a higher-level E/M

Orthopedic surgery practices that use the same E/M standards for pediatric and adult patients may be selling themselves short. If you rethink your history, exam and medical decision-making criteria, you can make the most of your work with your youngest patients.

Generally, orthopedic surgeons use the Centers for Medicare & Medicaid Services 1997 E/M documentation guidelines to assign appropriate levels for their specialty-specific services, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at CHAN Healthcare Auditors in Clayton, Mo. Based on this model, the more history and exam elements that you can check off, the higher your E/M level--and reimbursement--climbs.

Challenge: Although this bulleted checklist provides a concrete means of establishing E/M levels for new or established patients (99201-99205 or 99211-99215), it also contains several elements that are not applicable when evaluating young pediatric patients.

CMS itself recognizes this shortcoming and explains in its 1997 guidelines that the requirements -reflect the needs of the typical adult population.- It goes on to say, -Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area .- the content of a pediatric examination will vary with the age and development of the child.-

Bottom line: You can use other appropriate exam elements in place of the specific bulleted items, and then count these toward establishing a visit's E/M level.

Learn more: You can access the complete 1997 guidelines at www.cms.hhs.gov/medlearn/emdoc.asp. Expand Exam Options To properly assess the level of a single-system musculoskeletal exam, you must meet the following criteria:

-  Problem-focused: one to five elements

-  Expanded problem-focused: at least six elements

-  Detailed: at least 12 elements

-  Comprehensive: all elements identified by a bullet.

In other words, a comprehensive exam for a pediatric patient may be impossible without substituting certain tests.

Example: You perform all elements of a comprehensive musculoskeletal examination for a 10-month-old child who has a potential bone malformation. However, you are unable to complete the gait examination and orientation to time, place, and person. You perform a startle reflex test and measurements of cranial circumference. Mistake: Don't jump to a detailed examination because you can't check off each bulleted item.

Instead, make clear in your documentation that you performed the reflex test and cranial measurements in place of the specific, bulleted items due to the patient's [...]