Pediatric Coding Alert

The AAP has proposed guidelines that are relevant to pediatrics. These guidelines are now under review by an E/M workgroup at the AMA, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. Although not officially sanctioned by CMS, these guidelines will help pediatricians who now have little to go on but the guidelines for adults. After several more meetings, the last one in June, the workgroup will make recommendations to the CPT editorial panel.
 
An E/M service consists of three basic components: history, examination and medical decision-making. New patient E/M codes (99201-99205) require that all three components be met to justify a certain level; established patient codes (99212-99215) require only two of three.
Why the Diagnosis Counts
Do not base a level of service only on the diagnosis codes. The same diagnosis could mean a different level based on the situation. For example, an otitis media diagnosis such as 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) not requiring antibiotics could be a 99212, while a history of recurrent 382.00 possibly requiring surgery could be a 99214. Or, a patient might have a nonurgent diagnosis such as fatigue (780.79) and the medical decision-making involved may be complex enough to support a high-level code.
History
The history includes the chief complaint (CC), the history of the present illness (HPI), the review of systems (ROS), and the past, family and social history (PFSH), based on the level of service. For CPT 99201 and 99212, a problem-focused history must be documented, including CC and brief HPI. For 99202 and 99213, an expanded problem-focused history must be documented, including CC, brief HPI, and problem-pertinent ROS. For 99203 and 99214, a detailed history must be documented, including CC, extended HPI, a problem-pertinent ROS with additional systems, and a pertinent PFSH. For 99204, 99205, and 99215, a comprehensive history must be documented, including CC, extended HPI, complete ROS, and complete PFSH.
 
Code choice is technically based on the number of elements from each category. But looking at the CC and, sometimes, the diagnosis can give a better "feel" for a certain level.

Chief Complaint
 
Although the CC is essential to every E/M service, it does not necessarily affect the level of service. The CC may be the same as the final diagnosis.
 
The CC is directly related to the presenting problem, which contributes to the level of service chosen. The presenting problem is categorized as minimal (99211), self-limited or minor (99201, 99212), low severity (99202, 99213), moderate severity (99202, 99203, 99213, 99214), or high severity (99204, 99205, 99214, 99215).
 
For a neonate or infant, examples of a CC include normal newborn exam, cough, crying/irritability, feeding problems, rash, fever or difficulty [...]