Pediatric Coding Alert

See what this practice did right, and what it did wrong.

If you see a patient who has multiple problems, it can be easy to underestimate the amount of documentation that you actually produce. But that can lead you to undercoding your claims in some cases. Check out the following pediatric note submitted to Pediatric Coding Alert and see if you can spot where the coding went wrong.

Code reported: 99213

HPI: This nine-year-old female presents with:

Wrist pain. Onset: one day ago. Location: left wrist. The pain is sharp and continuous. Context: The patient was riding her skateboard at home yesterday and while going down a hill she fell and braced herself with her hands, causing the left wrist to be sore. She is unable to bend it without pain and this has affected her ability to brush her teeth and write.

Nasal congestion: Onset: About a week ago. There is an associated cough but the mother thinks it’s due to post-nasal drip. No fever or systemic symptoms. Nose is congested and when she blows it nothing comes out. Seasonal allergies have bothered her annually in the autumn.

PFSH: Patient is not on any medications. She has no known allergies. She lives with her parents and four-year-old sister and goes to public school. She skateboards and rides her bike for exercise.

ROS is positive for decreased mobility in her wrist and congestion in her sinuses.

Physical Exam

Musculoskeletal: Left wrist swollen. Tender over radius and thumb. Poor range of motion (ROM) to flexion and extension of wrist. Thumb and fingers with good ROM but pain with much flexion. Brisk capillary refill.

Respiratory: No cough. Lung sounds normal.

Constitutional: Level of distress is normal. Nourishment normal. Overall appearance normal.

Head/face: Skull is normal

Eyes: Left and right pupils, conjunctiva, sclera, and ocular muscles normal.

Ears: Left and right ears are normal on inspection, including canals and TMs.

Nose/mouth/throat: Clear discharge observed from both right and left nares with moderate hypertrophy. Mucosa are normal, uvula is normal, tonsils normal, and oropharynx is normal.

Neck/thyroid: Neck inspection is normal, neck range of motion is normal.
Lymphatic: Lymphatic system is normal
Abdomen: Abdominal tenderness negative

Psychiatric: Oriented to time, place, person and situation. Behavior is appropriate for age.

Assessment/Plan:

Elbow/forearm/wrist injury NOS (959.3)

Fall from skateboard (E885.2)

Comments: Normal x-rays of wrist

Allergic rhinitis (477.9)

Cockup splint placed. RICE for 2-3 days as needed. Recheck next week if not steadily improving. Loratadine daily, plus Benadryl as needed. Declines nose spray.

Spot the Problems

Unfortunately, this chart was undercoded for this patient since the chart qualifies for reporting 99214. The detailed history, detailed exam, and moderate complexity medical decision-making all support 99214.

Because 99213 pays about $72 and 99214 reimburses approximately $107, this physician forfeited about $35 by downcoding the visit by one level.

You can avoid this same fate by carefully calculating the amount of history, exam, and medical decision-making documented in your charts. With two new diagnoses, an x-ray, prescription management, and follow-up visits requested, this visit qualifies for moderate MDM.