Pediatric Coding Alert

Question: I saw a 16 year-old patient with an established diagnosis of syncope that our physician originally diagnosed a year ago. The patient requires a release so he can get a driver's license. The patient is doing well, and I didn't review or order any further testing. I also addressed a concussion that the patient mentioned during the history portion of the exam. He told me a sports medicine physician diagnosed the concussion four weeks ago and he is being followed by that physician for the condition. I signed the release forms for driving and I wanted to charge a 99214, but my coder said she only sees documentation for 99213. Obviously, this is a high-risk visit. Can you advise?

Codify Question

Answer: Although certifying this patient to drive, considering his history, does sound like a high-risk visit, if your documentation doesn't support the 99214, then you have no choice but to report the lower level code.

The only way you could report a 99214, in absence of the appropriate key element documentation, would be if you qualify to bill based on time. This would require you to have spent 25 minutes with the patient, at least half of which involved counseling or coordinating care. This would have to be documented in the record. For instance, "I saw the patient for 30 minutes, and spent 25 minutes advising him of safe driving techniques and the warning signs of a syncopal event so he knows when it's unsafe to drive."

Based on the information provided, this visit should be coded with 99213.