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 done during the exam.

5. The PFSH (Past, Family and/or Social History). There are three areas of patient history which you need to know about to comply with the guidelines:

Past history - the patients past experiences with illnesses, operations, injuries, and treatments;

Family history - a review of medical events in the patients family, including diseases which may be hereditary or place the patient at risk; and

Social history - an age-appropriate review of past and current activities.

Under the guidelines, there are two kinds of PFSH that need to be included:

Pertinent history is a review which is directly related to a present illness. At least one specific item for any of the three history areas must be documented for a pertinent PFSH.

Complete history is a review of two or all three of the history areas, depending on the category of the E/M service. Under the new guidelines, at least one specific item from two of the three history areas must be documented for a complete PFSH for an office visit for an established patient. And, at least one specific item from each of the three history areas must be documented for an office visit for a new patient.

6. Help with the ROS and/or PFSH. The review of systems and the past, family, and/or social history may be recorded by a nurse or other staff member, or on a form completed by the patient, the new guidelines state. The physician must review the information, however, and there must be a notation of this review in the file, as he or she is ultimately responsible.

7. Documenting general multi-system examinations. These are the exams most likely to be given by pediatricians, according to OHara. As in the past, there are four levels of E/M services:

Problem focused exam -- you only need to focus on one organ system or body area, and you only need to document one element.

Expanded problem focused exam -- you need to focus on at least six elements in one or more organ systems or body areas.

Detailed exam must include at least six organ systems or body areas, with at least two elements in each system or area. (Alternatively, a detailed exam could include at least 12 elements in two or more organ systems or body areas.)

Comprehensive exam must include at least nine organ systems or body areas, with documentation of at least two elements in each system/area.

Note: PCA subscriber benefit -- call 800/508-2582 to receive a fax outlining the guidelines' elements of examination and system/body areas in a general multi-system exam.

8. Dont under-code. Most pediatricians probably under-code their services, says Charles A. Scott, MD, FAAP, a coding trainer for the AAP. Scott believes too many pediatricians are using 99212 (problem-focused examination) or 99213 (expanded problem-focused examination) instead of 99214 (detailed examination). Problem-focused examinations (99212) should be limited to rechecks, he says. Or if someone says, My child has a rash, and you do the exam and find diaper rash, thats problem-focused. Scott tells us. Most sick visits are detailed examinations, he says. If youre seeing a four-month-old who has a fever and a cough and youre not sure whats going on, youre going to look at multiple organ systems, he says. You are doing a multi-organ system exam, and it should be coded as a detailed exam (99214). The new documentation guidelines tell you to document at least two elements in at least six organ systems for a detailed exam. And that, says Scott, is probably what youre doing anyway. Its just a matter of writing it all down. Dont be afraid to be aggressive with your coding, Scott urges pediatricians.

(Tip: If you are using the highest level code (99215) for an office visit, you will want to follow the comprehensive level of E/M services.)

9. Time spent counseling or coordinating care. If counseling or coordination of care dominates the encounter with the patient -- meaning if it takes up more than 50 percent of the visit -- the new guidelines consider time the key factor in qualifying for a particular level of service. Therefore, you have to record the actual amount of time spent with the patient (or parents). Documentation must also include a description of the counseling or coordination of care activities. Usually, the level of services will be chosen strictly by assessing the level of history, diagnosis, and medical decision making. Time overrides these three elements only if counseling dominates the encounter -- meaning it takes up more than 50 percent of the visit. For example, a child seen for diaper rash would be coded 99212 (problem-focused examination). However, if this exam is followed by a 15 minute discussion of feeding, teething, and car seats, time takes over, and you should use 99213 (expanded problem-focused examination).

10. Abnormal isnt enough. No matter what level you code the office visit, you must be specific about what you found in the exam, unless there were no negative findings. The chart cant simply say abnormal. From the new guidelines: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of abnormal without elaboration is insufficient. Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

11. Not pediatric-specific. Its difficult to say how these are going to affect pediatricians, says Carla McDonald, senior health policy analyst at the AAP. Its been a problem from day one: the guidelines will be enforced on pediatricians, but the codes arent pediatric-specific. The guidelines recognize this, and include an example of how the document could be made to apply to pediatricians. The example involves pediatricians somehow getting the prenatal records of the mother to ascertain a newborns health status.

However, there are some problems that the new guidelines limitations could cause pediatricians, notes Charles Schulte, MD, FAAP, who is the AAPs advisor to the AMA CPT Editorial Panel. Many of the bulleted items in these examinations are not appropriate for pediatrics. For example, the general multi-system examination includes rectal exams and description of the prostate gland -- not done on children. It also includes sitting and standing vital signs. What use is this with a preemie? asks Schulte. What these guidelines offer is a limited number of bulleted items that pediatricians have to choose from, which reduces the possibility to qualify for a higher level of service and get adequately reimbursed for the time spent treating the child. And the auditors who go over your claims may not be able to understand that this is an issue, Schulte explains. The AAP is working on a document that will be recognized by the AMA and HCFA which can be used by pediatricians to comply with the new documentation guidelines that better outlines the needs of pediatrics.

Note: In future issues of PCA we will look at other aspects of the new documentation guidelines, including how to document the complexity of decision-making.