Pediatric Coding Alert

After circling relevant items on chart worksheet after chart worksheet, you might feel like scrapping those aides for CPT's clinical examples. Before you do so, consider these history gathering time savers.

Let clinical examples be your guide, suggests the AMA.

"They are intended to serve as a tool to assist physicians in their understanding of the E/M codes and to guide them in determining appropriate E/M code levels," according to CPT Assistant's "Coding Communication" on E/M documentation guidelines (November 2008).

While that advice can seem like a time saver as compared to using an audit worksheet, the method isn't practical. "The number of clinical examples needed to adequately convey the message of the E/M documentation requirements would be far too vast to be effective," says Suzan Hvizdash, CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC Departments of Surgery and Anesthesiology.

Since leveling visits using only CPT's clinical examples is not feasible, consider using a tool, such as the Marshfield Clinic Tool (www.mrsiinc.com/MarshfieldAuditSheet.pdf).

Hvizdash uses a variation of the tool, which she usually finds "an easy way to explore the documentation." The Marshfield Clinic Tool helps offices develop templates, forms, and EMRs that outline documentation requirements. "When medical necessity has been met, the documentation will support the level of service billed," Hvizdash says.

The AMA, however, stresses, that CPT and CMS guidelines are not the same. "CMS used the template found in the E/M codes published by the AMA as the basis for the documentation guidelines," states CPT Assistant (Vol. 18, Issue 11, page 4). For example, CMS indicated how the various elements used to determine the level of history should be documented for a specific level of history described in an E/M code."

CPT guidelines are not as strict. You don't have to get, say, four history of present illness elements to qualify for an extended HPI (which could support a detailed history provided the other history elements of chief complaint, review of systems, and past, family, and/or social history are met), rather than a brief HPI supported by 1-3 elements (expanded problem-focused history).

CMS documentation guidelines, however, can be on your side when a pediatrician can't obtain a history. "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history," according to the 1995 and 1997 E/M guidelines.

In child abuse cases, "a history is often very difficult, if not impossible to obtain at the time of service, particularly when the parent is the alleged offender and has been taken into custody," says Dorothy Steed, CPC-H, CHCC, CPUM, CPUR, RCC, ACS-OP, CCS-P, RMC, CPC-EMS, CPC-FP, PCS, FCS, CPHM, CPAR, an independent consultant in Atlanta. "The physician must often rely on any information from DFACS or law enforcement and evidence gathered in the exam."

Action: To get credit for the unobtainable history, the pediatrician must illustrate the history piece that she tried to obtain and why she couldn't get that information. The physician could indicate that, due to the circumstances, she couldn't obtain an HPI. However, she might obtain PFSH from the medical record and a partial ROS from the case worker and police officer on the scene.

When "reviewing" documentation for a particular level of service, take both CPT's clinical examples and your E/M documentation guideline audit-based tool into account, Hvizdash recommends. Using this combination should prove more appropriate for high-risk patients.

For example, a patient being evaluated for a kidney transplant may have very few physical findings to justify a complete exam is not warranted. The complexity of the history and decision-making, however, should qualify for the highest level of service. "But, with the current process of counting elements under different sections, this visit would not support that high level because of a lack of required exam elements," Hvisdash says.