Pediatric Coding Alert

Review this documentation and determine how you’d code it before you read the solution.

When you see an unbelievably thorough E/M note, your first instinct may be to report a high-level code for the physician’s extensive work. But if even one element of a particular code isn’t met, you won’t be able to report it—even if the rest of the documentation is pristine.

As promised in our last issue, we’ll be sharing an E/M coding vignette each month to test your E/M coding finesse. See if you can spot the problems with this pediatrician’s note.

Code reported: 99223

Chief complaint: This is a 38-day old male patient admitted to the pediatric unit for fever and fussy behavior.

HPI: This is a 38-day old male patient admitted to the pediatric unit for fever and fussy behavior.

PMFSH: The baby was born at full term by cesarean delivery with uneventful labor and delivery. Birth weight was 8 pounds 1 ounce. The patient breastfeeds every two to three hours. He can smile and fixate on his mother’s face. Family history is significant for diabetes and dementia. No known drug or food allergies. Baby has been immunized against hepatitis B. The baby lives with his parents and 14 year-old sister in an apartment. Father smokes, but only outside. There are no pets.

ROS:

General: Fever

ENT: Negative for pulling at ears, no oral lesions, eye discharge, or redness.

PULMONARY: Positive for coughing, negative for shortness of breath

CARDIOVASCULAR: Positive for tachycardia

GASTRO: Positive for decreased oral intake and loose bowels. Negative for vomiting.

MUSCULOSKELETAL: Negative for joint swelling

ENDOCRINE: No diabetes or thyroid disorder that mother is aware of.

SKIN: Negative for skin rash

PSYCHIATRIC: Positive for irritability

NEUROLOGICAL: Negative for seizure

All other systems reviewed and negative

Physical Exam:

General: Patient is crying and slightly fussy

Vitals: Temperature is 101.4, pulse 189, respiratory rate 46, blood pressure 91/52, O2 saturation 100%, weight 9.3 pounds

HEENT: Anterior fontanel is soft and flat. Red reflex is positive. Right tympanic membrane is clear. Left tympanic membrane is erythematous and full. Wet oral mucosa. No oral lesions or cervical masses

Lungs and chest: Clear to auscultation bilaterally. No retractions

Cardiovascular: Tachycardia, S1 and S2. Regular rate and rhythm without murmur

Abdomen: Soft, nontender, nondistended. No hepatosplenomegaly. No masses.

Extremities: Full range of motion and moves equally

Genitalia: Normal male type without abnormality.

Skin: No lesions

Neurologic: Appropriate tone and strength

Laboratory data: Patient had white blood cells 9.5 with 72% neutrophils, 5% bands, 20% lymphocytes, hemoglobin and hematocrit 12.1/35.7, platelets 277. Serum electrolytes: Sodium 139, potassium 4, chloride 108, bicarbonate 22. BUN 5, creatinine 0.2, blood sugar 102, calcium 9.6. Urine test is white blood cells 2-4, and urine culture is pending. Blood culture pending. CSF: White blood cells 0, RBC 0. Gram stain: No bacteria. Protein 39.1 and glucose is 59 mg/dL.

Diagnostic studies: Chest x-ray normal.

Assessment/Plan: Would like to rule out bacteremia for acute pyrexia due to patient’s age and having fever with no obvious infection source. Start IV ampicillin 200 mg every 6 hours and Claforan 200 mg every 6 hours. IV fluid D5 ¼ normal saline with 20 mEq KCl/L to run at 16 mL per hour. Simethicone 20 mg every 6 hours for fussiness. I discussed the potential diagnosis with the mother and answered her question, and then advised the father to quit smoking.

Find Out Where This Pediatrician Went Awry

Did you spot the problems with this chart? Unfortunately, this chart can’t be coded. For initial hospital care, the minimal documentation to code the history is "detailed," but the documentation in this case only supports the expanded problem-focused level.

Here’s why: A detailed history requires four elements of the history of present illness (HPI), but this chart’s HPI is very sparse. The chief complaint is equally thin, so the coder wouldn’t be able to get any HPI from that.

HPI redo: To make this chart codeable, the HPI would need to say something more along the lines of "The baby has been fussy and has been crying for 12 hours straight (quality). He seems to cry in particular when he breastfeeds and makes bowel movements (modifying factors), so the mother believes he has a stomach issue (location). The crying began two days ago (duration) and occurs mainly in the afternoons (timing). He also has watery eyes and a fever (associated signs and symptoms). Now this HPI has five elements, thus making it codeable.

Time option: In the absence of an appropriate HPI, the pediatrician would be able to code the visit based on time spent with the patient if that was documented. To qualify for 99223, which the pediatrician in this case reported, the doctor would have to document 70 minutes spent at the bedside and on the patient’s hospital floor or unit, with at least 35 minutes of that spent counseling or coordinating care.

Resource: If you would like a copy of a pediatric audit tool, email our editor Torrey Kim at torreyk@codinginstitute.com and we’ll send it your way.