Pediatric Coding Alert

Question: Since prescription management involves moderate risk on the CMS standard documentation worksheet and the pediatrician in the following chart note (which appears exactly as written) prescribes medication, I am planning on submitting the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …Usually the presenting problem[s] are of moderate to high severity …). Is my visit leveling correct for this note:

8-year-old male; wt 114, temp 99.4, R 20; rash on face, arms, legs - mostly all over X 5 days. He held poison oak near his face four to five days ago. He often plays in the woods.

He has been using Lamisil anti-itch cream since it began.

Physical exam: alert, uncomfortable, Skin 1 x ¾ cm patch R nasal bridge, 1.5 x 1.5 cm patch R lower wrist area, 1 cm patch scrotum

Impression — Contact dermatitis; probable poison ivy. Prescribed Prednisone 10 mg/tab qid x 3 days, then Tid x 3 days, then Bid x 3 days, then Qam x 3 days. Benadryl prn.

Answer: Unfortunately, your documentation supports only a level two established-patient visit (99212, … problem focused history; problem focused examination, and straightforward medical decision making ... Usually the presenting problem[s] are self limited or minor …). Although a prescription is one element that can support medical decision-making for a 99214, it does not automatically make it a 99214 or even a 99213.

When you combine moderate risk with MDM’s other factors--Number of Diagnoses or Treatment Options (self-limited/ minor = 1 point), and Amount and/or Complexity of Data Reviewed (none = 0 points)--you get straightforward MDM.

In addition, medical decision making alone cannot drive a patient code if either the history or exam don’t support a particular code level. In your case, this visit would still not qualify for 99214 based on history and exam alone (two of three are required for 99212-99215). Using the 1995 E/M documentation guidelines, the exam, which is focused on the skin, is really a problem focused exam even though it technically includes two body areas/systems: constitutional (vitals, alert, uncomfortable) and skin. The documentation supports expanded problem focused history (requires three of three):

• Brief history of present illness (one to three elements: location - face, etc.; quality - all over; duration - x 5 days)
• Problem pertinent review of systems (one system: Integumentary)
• Comprehensive past medical, family, social history (PFSH) (Two areas: personal -- Rx Lamisil and anti-itch cream, and social -- plays in woods).

The straightforward MDM and problem-focused exam make the visit as documented qualify for 99212.