Pediatric Coding Alert

These questions will evaluate whether your E/M codes are on the straight and narrow.

Pediatricians report E/M codes more than they report any other service, but knowing whether you’re reporting these codes correctly is paramount to collecting the appropriate amount from insurers. Test yourself with these six questions and determine how your coding skills measure up.

Know Who Counts As ‘Established’ Patient

Question 1: The pediatrician saw a newborn in the hospital and reported both 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) and 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn) as well as 99238 (Hospital discharge day management; 30 minutes or less) during the baby’s hospital stay. The following week, the patient presents to your office for preventive medicine services. Which code should you report for the office-based visit?

A.    99381

B.     99391

C.     99202

D.    99213

Answer 1: B. Because the pediatrician provided face-to face-services in the hospital, the patient would be considered established in the office (even though it is the patient’s "first" visit to the office). This would support billing 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant [age younger than 1 year]).

Reminder: You have to keep the “three year rule” in mind for new patients. CPT says that a new patient is one who has not received any professional face-to-face services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Does E/M Format Matter?

Question 2: Your pediatrician reported established patient office visit code 99213, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. He insists that this is the way he has always done things, and there has never been a problem before. Is he correct that you can bill this claim without using the standard progress note?

1. No, the claim must be in the CPT-specified format
2. No, auditors would not accept the letter as proof
3. Yes, format doesn’t matter as long as the E/M elements are in the note
4. Yes, you can report the E/M since it’s an established patient and the rules are less stringent for them.

Answer 2: C. The format of a standard E/M progress note is typically recommended, but not technically required by insurers, so a letter could be allowable, depending on what information you can find in that letter. Is there a chief complaint, review of systems, medication reconciliation, physical examination, and other similar documentation in the letter that supports 99213? If so, then it should hold up as documentation of the patient’s visit.

If, however, the letter simply states, “Thank you for referring Aidan Smith. I concur with your assessment of asthma and have recommended medication,” then you won’t meet the criteria for 99213 because you don’t have enough information (history, exam, and medical decision-making) to support the code.

New Patient Rules Are Tricky

Question 3: We found several instances where our physician saw a new patient but didn't document the minimum levels of history required (he either documented no chief complaint or no HPI) to bill any new patient office visit codes (99201-99205). What can we report in circumstances like this?

A) Use an established patient code (99211-99215)

B) Select the appropriate new patient E/M code with modifier 52 (Reduced services) appended

C) Report 99499 (Unlisted evaluation and management service)

D) You can’t bill an E/M for a new patient with no history.

Answer 3: D. Review the brief HPI information the physician documented to determine if the statement contains both elements of a CC (chief complaint) and history of present illness (HPI). The doctor must document the HPI, exam (with the exception being vitals, which an ancillary staff member can document), and the medical decision making (MDM). You need documentation of all three key components (history, exam, and MDM) to support even the lowest new patient level E/M code.

If you truly have no HPI documentation, you cannot submit a claim with the new patient E/M codes (99201-99205). Help educate your providers on the importance of clear E/M documentation. The HPI is a vital part of the patient record that documents the reason why the patient is seeking care and the circumstances surrounding the problem that led up to and includes the present status and any changes since the patient's last visit. If a physician routinely omits the HPI, you'll be hard pressed to establish medical necessity for many patient encounters.

Exception: The initial visit can be coded based on time if more than 50 percent of the face to face visit is spent counseling or coordinating care, and it’s documented in the medical record.

Can You Rely on EMR Codes?

Question 4: The pediatrician is a very thorough documenter and often treats very sick patients. Because he documents his EMR so well, almost all of his cases qualify for 99214s and 99215s. Since the documentation supports his code selections, is this acceptable?

A)    Yes, as long as he documents a thorough exam, history, and MDM, you are fine

B)    Yes, you should always trust the EMR’s code choice

C)    No, the E/M code should be driven by medical necessity

D)    No, you should code based on time

Answer: 4: C. Your electronic health record will most likely offer an E/M code suggestion at the end of each visit--but that doesn't mean you can use that to justify all high-level codes.

Several practices have told Pediatric Coding Alert that their physicians “thoroughly document” the History and Physical Exam elements for all conditions, leading to high-level codes, even if the medical decision-making (MDM) doesn't support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three criteria (History, Exam, MDM).

Reality: CMS indicates in its Carriers Manual that "Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT® code." In addition, the 1995 E/M Guidelines state, "The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results." Most Medicaid payers and many private insurers also follow these guidelines.

Are Vitals Imperative?

Question 5: A mother brings her daughter to your office after hours, when the nurse is gone for the day. The doctor sees the child, but he doesn’t take any vitals. He documents the office visit for this "no appointment add-on" service, but says that you cannot bill for the encounter since you didn’t take vitals. He did document everything else (history, exam, medical decision making). The office manager believes the practice can bill for the visit. Who is correct?

1. The physician is right--you can’t bill without vitals
2. The office manager is correct--if the documentation meets the E/M code requirements, you can bill it without vitals

Answer 5: B. Although they are almost always documented, vitals are not required in order to bill an E/M visit. Vitals are important -- and usually the norm -- but really are just another component of the exam. Since the physician documented the history, exam, and level of medical decision making, he should have sufficient notes for the practice to choose the correct E/M code.

Don’t Jump to Report E/M Codes

Question 6: Our nurse gave a patient an allergy shot. Which E/M code can we report with it?

A.    99211

B.     99211-25

C.     None

D.    99212

Answer 6: C. You can't bill 99211 for just an allergy shot or vaccination. For allergy shots, you should code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for a single shot or 95117 (...2 or more injections) for two or more shots.

If the billing provider supplies the allergy serum, then you should bill for the serum at the time the provider makes the new serum. For vaccinations, bill the vaccine separately and use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for a single injection, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for a single nasal/oral vaccination, or +90472 for each additional vaccination.

Note: If the nurse provides a separate, medically necessary E/M service -- for example, if the patient has a separate illness or a reaction to the injection that requires a separate evaluation -- then you can separately bill for these services using 99211 with modifier 25 appended. Make sure the documentation supports these services.