Pediatric Coding Alert

Find out what this practice did wrong so you can avoid making these mistakes.

You’re probably coding E/M notes several times a day at your practice, but if you’re always relying on the pediatrician’s code selection without checking the documentation, you could be submitting incorrect claims. It’s a good idea to do an internal audit occasionally to ensure that the practitioners and coders are on the same page.

Take a look at this real-world pediatric documentation to determine what the practice did right and what they did wrong. This will be the first in a series of E/M vignettes that we share to help you code your E/M notes appropriately.

Code reported: 99204

Chief complaint: Follow-up visit for one week old patient previously evaluated
at birth.

HPI: See chief complaint.

PFSH: NKDA, no medications, lives with both parents who are healthy and living. No smoking in the home, uses car seat, family history non-contributory.

ROS: Parent reports no skin dryness, redness, rash, hives, lesions, lumps, swelling, or bruising. Jaundice is improving per mom, who reports no significant weight change, good appetite, no fever, normal activity level, and a happy disposition. The mother reports no eye redness, swelling, or discharge, and normal eye movement. There is no ear discharge, drooling, facial swelling, congestion, or mouth lesions. There are no lumps, tenderness, or discharge, no wheezing, normal respiration, no vomiting, diarrhea, constipation, or blood in stools. The child moves all extremities well and eats and drinks at normal intervals. The mother reports no sneezing or runny nose.

Physical exam:

General appearance: Active and alert, no acute distress, attentive.

Head: No tenderness or swelling

EENT: Eyes: round, equal size, reactive to light, with no exudates. Ears: Tympanic membranes pearly with good landmarks, pinna well-formed, and no pits. Nose: No crusts/sores or nasal discharge and patent. Tonsils: No erythema or exudate and not enlarged.

Neck: Supple and no lymphadenopathy

Cardiovascular system: Heart sounds normal S1, S2, and femoral pulse; no murmur, gallops, or rub; and regular rate and rhythm.

Lungs: Auscultation: No wheezing, rales/crackles, rhonchi, tachypnea, or retractions and clear to auscultation.

Abdomen: Auscultation: Normal bowel sounds. Palpation: No tenderness or masses. Liver: No hepatomegaly. Spleen: No splenomegaly.

Skin: General: No cyanosis, good turgor, and generalized warmth. Moisture: dry. Lesions: No petechiae or rash; jaundice

Assessment/Plan: Unspecified fetal jaundice (774.6) – level of T bili stabilizing, with normal neuro exam. Continue breastfeeding. Bring patient back next week for another bilirubin test and call with any questions.

Did You Spot the Problems?

Problem 1: There are several issues with this note, starting with the fact that the physician marked this as a “follow-up visit.” This seems to conflict with the fact that a new patient code was selected. You can only report a new patient code if the patient has not been seen by the physician or another practitioner in the same practice of the same specialty within the past three years. Even if the pediatrician only saw the patient in the hospital on the day of her birth (and not previously in the office), the patient is established. Therefore, you must ask the physician whether she saw the patient at birth or whether another practice or hospitalist did that previous evaluation before knowing whether to report a new or established patient visit.

Problem 2: The second issue involves the chief complaint, which should not simply say “Follow-up.” Instead, the chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient’s own words. An example would be a “baby check-up,” or “jaundice.” Just stating “follow-up” is not appropriate.

Find it: Although some coders were trained to only look for a chief complaint in one particular section of the documentation, that is inaccurate. The chief complaint may actually be listed as a separate element of the history, or it may be included in the history of present illness (HPI).

Unfortunately in this case, the pediatrician referred back to the chief complaint in the HPI. However, in the review of systems, it notes that jaundice “is improving,” so the chief complaint is most likely checking in on the patient’s bilirubin, which would be stated by the parents as “jaundice re-check.” You should confirm this with the pediatrician.

Problem 3: The pediatrician did not document the history of present illness (HPI), and every E/M service level requires an HPI of either brief or extended. According to the documentation guidelines for E/M services, the physician must document the HPI portion of the history, and history requires at least one element of the HPI. Further, you need documentation of all three key components (history, exam, and medical decision making) to support a new-patient level E/M code. If you truly have no HPI documentation, you cannot submit a claim for a new patient encounter based on the history, exam, and medical decision-making.

Time may help: If the physician spent more than half of her time with the patient in counseling and/or coordination of care and documents such, then you may be able to code the visit (new or established patient) on the basis of time, rather than the key components of history, exam, and medical decision making. If the physician elects to report the encounter based on counseling and/or coordination of care, then he should document the total length of the encounter (i.e. face-to-face time in the office), time spent counseling/coordinating care, and describe the counseling and/or activities to coordinate care.

Follow up: Help educate your physicians on the importance of clear E/M documentation. The HPI is a vital part of the patient record that documents the nature of the patient’s problem and what has happened since its onset or since the patient’s last visit (in the case of an established patient with a previously diagnosed problem). If a physician routinely omits the HPI, you’ll be hard pressed to establish medical necessity for many patient encounters.

Which Code Should You Choose?

Review the previous documentation or query the physician to confirm that the doctor saw this patient in the hospital. Since the physician uses the phrase “previously evaluated at birth,” it’s not totally clear that this doctor is the one who saw the patient at birth. If your doctor saw the patient at the hospital and this is an established patient, you should report 99213.

Here’s why: Without HPI, this history is not billable, but you can count the detailed exam and low medical decision-making to report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components ...). Because established patient visits require only two of the three key components, she has met the requirements for a 99213.

If, however, you learn that this is indeed a new patient, the visit is not billable without the history of present illness. Again, the only caveat to this is if the doctor coded based on time spent with the patient as well as the time spent counseling or coordinating care. This must be carefully documented.