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Pediatric Coding Alert

E/M Coding:

Watching the Clock Helps Determine When to Choose 99215

Published on Tue Jul 13, 2010

Tip: Split documentation to make calculations easier.If lengthy patient visits leave you wondering when to bump your E/M code up to 99214 or 99215, use our real-life example from Mary Noahr, office manager for Birth and Beyond Pediatrics in Tulsa, Ok., to help make the call.Scenario: Parents brought their child to the office for a 9-month well visit. Additional diagnoses from the visit include failure to thrive (FTT), established diagnoses of eczema and reflux, and feeding problems. The parents declined reflux medications and UGI (upper gastrointestinal) tests at earlier visits, and refused to see a dietitian. The pediatrician spent approximately 1 hour and 15 minutes total with the patient and parents. She documented spending 45 minutes on feeding/eczema discussions. Documented services include:Writing a prescription for eczema treatmentPerforming a complete physical exam and anticipatory guidance due to the well visitDiscussion on FTT and eczema issues on a separate progress note.Challenge: The [...]
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