Pediatric Coding Alert

The revised documentation guidelines for Evaluation and Management (E/M) Services have all physicians, especially those with Medicare patients, in a tizzy. Even pediatricians, who generally dont have Medicare patients, are concerned. But its important to remember that these guidelines involve documentation only, and furthermore you are probably already doing much of it. The American Medical Association (AMA), which writes the guidelines in concert with the Health Care Financing Administration (HCFA), notes that most of the guidelines are for use by specialists.

The guideline for General Multi-System Examinations would be the one most likely used by pediatricians. Here are key points to remember about the new documentation guidelines, which were issued on October 1, 1997, and which HCFA will start enforcing for Medicare patients January 1, 1998.

1. These are guidelines, not rules. As the AMAs Karen OHara, project manager of the AMAs CPT Information Services puts it, a lot of people dont realize that these are just guidelines, not a law. However, HCFA is going to take them seriously, and if you get audited, you will have to show you are meeting them.

2. Beyond Medicare? Pediatricians with no Medicare patients (the only children on Medicare are those with end-stage renal disease) still need to pay attention to the documentation guidelines. Thats because many of the state Medicaid carriers follow HCFAs structure, and more and more private managed care companies are doing so as well.

3. No big changes in what you do. The new documentation guidelines are not going to change what youre already doing in terms of examinations, says Janet McDiarmid, CMM, CPC, MPC, president of the American Academy of Procedural Coders Advisory Board. This was done to appease the specialty societies, she says, noting that specialists didnt feel the existing documentation guidelines recognized their work adequately. Its not changing the way I code, asserts McDiarmid, who is also clinic administrator for James Williams, MD in Sylacauga, AL.

4. Keep track of documentation. Its a good idea for the doctors staff to keep track of how he is documenting examinations, McDiarmid tells us. If something isnt in the chart, I take it back to the doctor and tell him he hasnt written enough for that level of service, she explains. He can do the documentation after the patient has left -- nothing says you have to write it down while the patient is there. Remember, a coding person cant do the physicians coding or documentation. The person who did the examination has to do it, since he or she is the only one who knows what was actually [...]