Pediatric Coding Alert

One common peds encounter could lose value in 2021, say our experts.

Now that we have a clearer understanding of how we will calculate office and outpatient evaluation and management (E/M) service levels beginning Jan. 1, 2021, it’s time to take a look at the fine details and determine how they may affect pediatric revenues next year.

Here is a typical peds encounter, leveled using current 2020 guidelines and the new 2021 guidelines. What our experts found may surprise you  and give you pause for thought.

The Note

An established 9-year-old female patient reports with moderate bilateral ear pain extending down the inside of the neck, which she rates as a 7 on a scale of 1-10; and postnasal drip, both of which she has had for a week. The patient denies trauma, tinnitus, or ear discharge, and also denies nausea, vomiting, fever, chills, dizziness, or lightheadedness. She says that her father is a cigarette smoker.

 In the exam, the provider notes the following: Constitutional: appears non-toxic but is holding her ears. Ears, nose, mouth, and throat: finds postnasal drip and clear ear canals with no perforations or growths but with mild wax buildup and a mild, bilateral inflammation of the tympanic membranes. Respiratory: no crackles or wheezing. Cardiac: regular rate and rhythm with no abnormal sounds. Abdomen: not tender or distended. Skin: no rash.

The provider diagnoses the patient with bilateral otitis media and postnasal drip. She prescribes amoxicillin, fluticasone nasal spray, and ofloxacin ear drops.

The entire encounter takes the provider 25 minutes, all of them face-to-face with the patient.

E/M Level Per 2020 Guidelines

Under current guidelines for established patients, you can use two out of the three E/M components (history, exam, and medical decision making [MDM]) to determine the level of the E/M.

History: Here, there is enough in the note to justify a detailed history. “Using the 1995 guidelines, this would be based on a four-element history of present illness (HPI) (the duration, severity, and location of the pain along with the associated signs and symptoms); a four-system extended problem-pertinent review (ROS) (reviews of the constitutional; ears, nose, mouth, and throat; respiratory; and cardiac systems); and documentation of the father’s cigarette smoking, which is a pertinent part of the patient’s past, family, and social history (PFSH),” says Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

Exam: “Again, there is enough in the note to justify a detailed exam based on the provider’s exam of the affected body area (the ears, nose, mouth and throat) along with the other organ systems,” Walaszek observes.

MDM: “Per the note, the provider has determined the patient has two self-limited or minor problems. The provider has not ordered any diagnostic procedures or reviewed any data but has prescribed three medications. This adds up to a moderate MDM level,” according to Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

As the 2020 E/M guidelines require that “two of the three key components (ie, history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for a particular level of [office] E/M services,” this means that, no matter which element you discard  the detailed history, a detailed exam, or the moderate MDM  the scenario gives you a solid E/M level of 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity …).

Levelling Under 2020 Time Guidelines

Under 2020 rules, you cannot use time to code this encounter. That’s because “counseling and/or coordination of care” has not dominated (taken up more than 50 percent) of the “encounter with the patient and/or family,” and so cannot be considered as “the key or controlling factor to qualify for a particular level of E/M services.”

Had counseling dominated the encounter, however, and your pediatrician was able to document it, the E/M would still stay at a level four. That’s because the descriptor for 99214 states that “typically, 25 minutes are spent face-to-face with the patient and/or family.”

What Happens to the Same Scenario on Jan. 1, 2021?

“As we know, in 2021 a provider will be able to choose an E/M code based on time or MDM,” Walaszek reminds coders. “If you chose the first option and code based on time, the documentation supports 25 minutes, face-to-face. This equates to 99213 [Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter]. This couldn’t get any simpler,” Walaszek notes.

Significantly, you would arrive at the same level even if you chose MDM as the determining factor. Using the proposed 2021 CPT^® MDM table (www.ama-assn.org/system/files/2019-06/cpt-revised-mdm-grid.pdf), the scenario details two self-limited, uncomplicated illnesses, a limited amount/complexity of data to review, and a moderate risk of complications based on the ordering of prescription medications. That makes two out of the three elements limited or low, creating a low-level MDM, corresponding to a 99213.

The Bottom Line

Even though this common peds scenario will probably result in a lower-level E/M in 2021, it is impossible to predict at this point whether all peds encounters will be downgraded next year once the new guidelines take effect. So, an audit of your current E/Ms using 2021 guidelines with a large sample will be a better predictor of your revenue stream in the New Year and beyond.

Coding caution: CPT^® has yet to finalize the methodology for leveling office and outpatient E/Ms, and last-minute changes to the guidelines could result in this encounter being billed at a different level from the 99213 our experts have predicted for 2021. Additionally, the Centers for Medicare & Medicaid Services (CMS) has yet to issue its final rule regarding payments for services, so the effect of the changes on your bottom line may not be as great compared to this year.

Be sure to consult subsequent issues of Pediatric Coding Alert to see how changes in either of these things will affect you moving forward.