Pediatric Coding Alert

Omitting this detail could cut a 99214 to a 99213If time-selected E/M documentation does not detail three requirements, you could be faced with writing a huge payback check.That's the lesson one pediatrician learned. See if you can spot the problem with this chart entry.An 8-year-old boy seen for ADHD (chief complaint) FU (HPI-duration) visit. He has been on stimulant medication (HPI-modifying factor) for one month (HPI-duration) but is not doing well (HPI-quality). He is still having problems attending school (social history-education) and with off-the-wall behavior at home (HPI-severity). His parents have not noted problems with appetite (ROS-constitutional) or sleep issues (ROS-neurological or respiratory-not both). Physical examination consists of a brief neurological examination (can't give credit here as there are no details). Extensive counseling is done for school and behavioral issues, his diagnosis of ADHD and treatment options (counseling description). His stimulant dosage is increased (prescription drug management-table of risk-moderate) (MDM risk: 2 pts) and FU planned in one month. Total face-to-face time is 25 minutes (can't use this without knowing how much of that time was spent counseling). Step 1: Include 3 Items in DocumentationBefore using time as the controlling factor, check off the following requirements from Lisa Curtis, CPC-I, CPC-E/M, who specializes in E/M audits in the Greeley, Colorado area. To code based on time, the physician must document:1. the total time spent with the patient2. that more than 50 percent of the face-to-face time the physician spent with the patient/and or family is counseling/coordination of care. "I advise my providers to state the actual time (for instance 45 minutes was spent with the patient in total, 30 minutes in counseling)," Curtis says.3. a description or summary of the counseling/coordination of care.Problem: Although the documentation in the previous chart indicates the encounter's total face-to-face time (25 minutes), the pediatrician fails to indicate the percentage of the encounter that the physician spent on counseling and/or coordination of care. CPT lets you select an office visit code based on time only when the physician spends more than 50 percent of the face-to-face time with the patient and/or family member on counseling and/or coordination of care, explains Richard H. Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville. "If documentation does not specify that the encounter has met the more than 50 percent counseling requirement, you cannot use time as the controlling factor to select the level of E/M service."Step 2: Use Elements When % UnknownYou instead have to code the visit based on the documented history, says Suzan Hvizdash, CPC, CPC-E/M, CPC-EDS, medical auditor, University of Pittsburgh Physicians. Her breakdown of the note linked to the italicized chart entry explanations includes:• HPI-quality, severity, duration, modifying factors-EXTENDED• ROS-Constitutional, Neuro (or [...]