Pediatric Coding Alert

Question: During an office visit, my pediatrician performs an expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making. Which level of E/M service should I report? Does the patient's status, new or established, affect the level?

Washington Subscriber Answer: Because established patient visits require only two of the three components, but new patient visits require all three components, the patient's status will change the office-visit level. If this is an established patient, the visit qualifies for a level-three office visit (99213, Office or other outpatient visit for the evaluation and management of an established patient ...). You should report 99202 (Office or other outpatient visit for the evaluation and management of a new patient ...) for a new patient.

For an established patient, you may disregard the lowest of the three components. In the above scenario, you may ignore the straightforward medical decision-making, which leaves you with an expanded problem-focused history and an expanded problem-focused examination. The two highest elements meet 99213's requirements.

Because new patient visits require all three key components, you should report new patient E/M services based on the lowest component. In this case, the pediatrician uses straightforward medical decision-making, which qualifies for 99201-99202. Because she also performs an expanded problem-focused history and an expanded problem-focused examination, you should code a new patient visit with 99202.