Pediatric Coding Alert

Pediatricians who see four to six patients an hour may think they dont have time to calculate the appropriate level evaluation and management (E/M) service for every visit. But choosing the right E/M level may be the most important thing you can do for your bottom line. Unfortunately, many pediatricians undercode because they think it will protect them from audits. And they also do it for a more troubling reason: They lack the self-esteem to code what their services are worth, says Peter Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine and a practicing physician with Pediatric Associates of Brockton, in Brockton, Mass.

CPT Codes offers clear guidelines for selecting an E/M level, which allow you to base coding decisions on objective criteria, not a vague estimation of the value of your work. Following these guidelines will provide a solid defense against audits while optimizing reimbursement.

Pediatricians should select E/M levels using the elements with which they are already familiar: history, examination and medical decision-making. Understanding the factors that determine the level of these individual elements not just the E/M codes themselves will allow coders to mix and match elements to arrive at the appropriate E/M level for all established patient office visits (99212-99215).

Know the Requirements of Each Level of Element

The elements of history and exam can range from problem focused (the lowest level) to comprehensive (the highest level). Medical decision-making likewise spans four levels, ranging from straightforward to highly complex. Each level of each element must meet the following criteria:

History
Problem-focused
Chief complaint
Brief history of present illness

Expanded problem-focused
Chief complaint
Brief history of present illness
Problem-pertinent system review

Detailed
Chief complaint
Extended history of present illness
Problem-pertinent system review with an additional review of a limited number of additional systems
Pertinent past, family, and/or social history directly related to the problems discussed

Comprehensive
Chief complaint
Extended history of present illness
Review of systems related to the present illness plus review of all additional body systems
Complete past, family, and social history

Examination

Problem-focused
Limited examination of affected body area or organ system

Expanded problem-focused
Limited examination of affected body area or organ system and other symptomatic or related organ system(s)

Detailed
Extended examination of the affected body area(s) and other symptomatic or related organ system(s)

Comprehensive
General multi-system examination or complete examination of single organ system

Medical Decision-making

Straightforward
Minimal number of diagnoses or management options
Minimal or no data to be reviewed
Minimal risk of complications and/or morbidity or mortality

Low complexity
Limited number of diagnoses or management options
Limited amount and/or complexity of data to be reviewed
Low risk of complications and/or morbidity or mortality

Moderate complexity
Multiple diagnoses or management options
Moderate amount and/or complexity of data to be reviewed
Moderate risk of complications and/or morbidity or mortality

High complexity
Extensive number of diagnoses or management options
Extensive amount and/or complexity of data to be reviewed
High risk of complications and/or morbidity or mortality

Determining the Level of Medical Decision-making

Unlike the history and examination, for which a coder can review chart notes and see if the E/M level was justified, medical decision-making is a clinical determination that can only be made (and documented) by the examining pediatrician.

Its really hard to quantify medical decision-making, says Diana Arbes, CPC, reimbursement analyst with Childrens Hospital Pediatric Physicians of the Oklahoma University Health Sciences Center in Oklahoma City. You need to consider the risk of morbidity or mortality.

Risk is based on the presenting problem, the diagnostic procedure and the possible management options, as illustrated by the following examples:

Presenting Problems: upper respiratory infection (URI) (minimal risk), simple sprain (low risk), head injury with brief loss of consciousness (moderate risk), psychiatric illness with potential threat to self or others (high risk)

Diagnostic procedures: urinalysis (minimal risk), pulmonary function test (low risk), extensive blood studies (moderate risk), lumbar puncture (high risk)

Management options: cool-mist humidifier (minimal risk), over-the-counter medication (low risk), prescription drug management (moderate risk), drug therapy requiring intensive monitoring for toxicity (high risk)

Know the Requirements of Each E/M Level

All established patient codes require that two of the three key elements of history, examination and medical decision-making be met.

Note: For new patient codes 99201-99205, all three elements must be documented to the appropriate level.

99212: Problem-focused history and examination, straightforward medical decision-making

99213: Expanded problem-focused history and examination, low complexity medical decision-making

99214: Detailed history and examination, moderate complexity medical decision-making

99215: Comprehensive history and examination, high-complexity medical decision-making

Use Caution When Coding 99215

Pediatricians bill mostly 99212 and 99213. The bell-shaped curve with 99213 being billed the most frequently, an equal number of 99212s and 99214s and another equal but much smaller number of 99211s and 99215s is ideal for the hypothetical average practice. Most pediatricians have a spike at 99212 or 99213, not a bell-shaped curve, Rappo says. If your practice treats more than the average number of acutely or chronically ill patients, your bell curve will be skewed to the right, reflecting the greater number of 99214s and 99215s

But Rappo warns that justifying a 99215 can be difficult. Consider the level of detail required for the comprehensive history alone, he says. You need a complete personal, family, and social history. You need to know what the parents do for a living. If Dad works as an accountant, thats one thing. If he works in a heavy-metals factory where hes exposed to toxic materials, thats another. You need to document the past occurrences of the problem. Yes, its all in the chart, Rappo acknowledges. But for documentation, you need to reference this in the chart note for the day you are billing the 99215.

Treatment of a hematology-oncology patient who is receiving chemotherapy serves as a good example of when coding 99215 is justified, Arbes says, because of the extensive level of history, exam and medical decision-making involved. A 3-month-old child with bronchiolitis, however, may not warrant a 99215. If there is acute respiratory distress, and it is documented, then that may be a level five, admits Arbes. But you still need the complete exam or the complete history.

Rappo agrees. It may well just be a 99214. You have to document a lot for a comprehensive history.

Remember, however, that medical decision-making is a very powerful element and can often determine the level of E/M. For a child whose case encompasses medical decision-making of high complexity, you need only a comprehensive history or a comprehensive examination to code 99215.

Examples of Elements

CPT provides plenty of vignettes to illustrate different E/M levels, but offers no examples of different levels of elements. What, for instance, would constitute a comprehensive history or an expanded problem-focused examination? Richard H. Tuck, MD, FAAP, a member and founding chair of the American Academy of Pediatrics coding and reimbursement committee, has prepared chart notes as examples of each element at each level.

Tucks examples, provided below, show how chart notes documentation should look for elements when coding each level.

Note: Remember that you must document two of three elements at a certain level to bill that level. If, for instance, you record an expanded problem-focused history (99213), a detailed examination (99214) and straightforward medical decision-making (99212), you would be able to bill 99213, because two elements at the level of 99213 or above have been documented.

99212: Contact Dermatitis

History: Problem-focused
Chief complaint: Rash
History of present illness: Itching for two days, having been outside in the woods

Examination: Problem-focused
Examination of skin: Erythematous patchy vesicular rash with linear lesions
Diagnosis: Contact dermatitis

Medical decision-making: Straightforward
Number of diagnosis/management options: Minimal
Data reviewed: None
Risk of complications: None

99213: 4-year-old With URI

History: Expanded problem-focused
Chief complaint: Cough
History of present illness: Congestion for one week, wet cough for four days, no fever, decreased appetite and poor sleeping patterns
Problem-pertinent system review: Ear no earache; throat no sore throat; gastrointestinal (GI) no vomiting

Examination: Expanded problem-focused
Weight, temperature, respiratory rate; ears tympanic membranes clear; nose congested, thick clear mucus; pharynx mild erythema; chest clear to auscultation; heart normal rhythm, without murmur; abdomen soft, without masses or tenderness

Medical decision-making: Low complexity
Number of diagnosis/management options: Limited (possibly URI, bronchitis or sinusitis; possible treatment options: decongestants, analgesics or antibiotics)
Data reviewed: Limited (temperature and respiratory rate)
Risk of complications: Low

99214: 7-year-old With Pneumonia

History: Detailed
Chief complaint: Cough
Extended history of present illness: Coughing for one week, increased severity for three days, fever to 102 for two days, labored breathing for one day, vomiting for one day, tolerating fluids and voiding normally
Review of systems: Problem-pertinent no earache and mild sore throat
Additional review of systems (limited number):
Skin no rashes; neurological alert and responding normally; mild gastrointestinal pain
Past history: Pneumonia twice last year
Family history: Others in family with colds and coughs
Social history: Both parents smoke

Examination: Detailed
Weight, temperature, respiratory rate, pulse oximetry; skin clear, no cyanosis; ears tympanic membranes clear; nose mild congestion; pharynx mild erythema, mucous membranes moist; neck supple; chest moderate distress with tachypnea, subcostal retractions, and inspiratory rales bases bilaterally with occasional wheezing, symmetrical air exchange; heart regular rhythm, without murmur; abdomen soft, mild diffuse tenderness to palpation, normal bowel sounds; neurological subdued, but interacting normally with mother

Medical Decision-making: Moderate complexity
Number of diagnosis/management options: Multiple (diagnosis could be pneumonia, bronchitis, sinusitis or reactive airway disease; management options include admission with oxygen, or outpatient oral or intra-muscular antibiotics, bronchodilators or antipyretics)
Data reviewed: Moderate (temperature, respiratory rate, chest x-ray and pulse oximetry)
Risk of complications: Moderate (potential sepsis or progression to respiratory failure)

99215: 14-year-old With Abdominal Pain

Comprehensive history
Chief complaint: Stomach aches
Extended history of present illness: Abdominal pain for past six months; intermittent, worse after meals, especially spicy foods and dairy products; present weekends and weekdays, now acutely worse and continuous for two days; occasional nausea, no vomiting; occasional loose stools with diarrhea for two days and increasing nausea; occasional bright red blood in stools; occasional gas (belching and flatus); no weight loss; last menstrual period two weeks ago, normal period; one week of school missed due to abdominal pain
Review of systems: No fever; skin no rashes; no earache, sore throat or congestion; respiratory no cough, wheezing or chest pain; cardiovascular no chest pain or palpitations; genitourinary normal voiding, no dysuria, regular periods with moderate discomfort and moderate bleeding, no discharge; musculoskeletal occasional leg pain, no swelling, limp or erythema; neurological occasional headaches and dizziness; psychiatric no unusual behaviors
Past history: Occasional abdominal pain in past, normal growth and development
Family history: Mother with abdominal pain diagnosed as ulcerative colitis
Social history: Straight A student, stressed by school, one week of school missed due to abdominal pain, not getting along with parents and family, parents separated, denies sexual activity

Examination: Comprehensive
Height, weight, blood pressure, urinalysis, stool tests; skin clear, turgor good; eyes pupils equal and reactive to light, fundi benign and optic discs sharp; ears tympanic membranes clear; pharynx benign, mucous membranes moist and pink; neck supple; chest clear, symmetrical air exchange; heart regular rhythm without murmur, pulse normal and symmetrical; abdomen soft, without masses, increased bowel sounds, diffuse tenderness to palpation without rebound, without hepatospleno-megaly; rectal normal rectal tone, soft stool (guaiac: negative); genitalia normal female external genitalia, no discharge; nodes without significant adenopathy; neurological normal muscle tone, strength and symmetry (gait normal, deep tendon reflexes symmetrical)

Medical decision-making: High complexity
Number of diagnosis/management options: Extensive (diagnosis could be gastritis, ulcer, colitis, gall bladder disease, lactose intolerance, functional abdominal pain, chronic inflammatory bowel disease, ovarian cyst or mid-cycle ovulatory pain, or gastroenteritis; treatment options include milk-free diet, other dietary modifications, trial of Prilosec, stress relief, sequential exams during acute phase of illness, possible referral to gastroenterologist, stool studies [culture and sensitivity], imaging studies, ultrasound or endoscopies)
Data reviewed: Extensive (weight, height, blood pressure, lab complete blood count, serum glutamic-oxoloacetic transaminase, serum glutamic-pyruvic transaminase, blood urea nitrogen, creatinine, sedimentation rate, urinalysis and stool for occult blood)
Risk: Moderate to high without treatment

Note: Some payers may not accept a diagnosis of abdominal pain (789.0x) because it lacks specificity. This is irrelevant to justifying an E/M level, which is done according to CPT.

A Note About Time

Time is not a factor in choosing an E/M level, with the exception of counseling or coordination of care. If more than 50 percent of the encounter is spent on these activities, you may bill using time as a key element. CPT outlines the following time definitions for established patient office visits: 99212 (10 minutes), 99213 (15 minutes), 99214 (25 minutes) and 99215 (40 minutes).