Pediatric Coding Alert

Question: Which code should we report for evaluation of a cough, runny nose, and fever? We can’t decide whether it should be 99212 or 99213, but the pediatrician actually marked 99214.

Maryland Subscriber

Answer: This question highlights a common myth — that each type of diagnosis has a standard evaluation and management (E/M) code associated with it. However, your E/M code should be based upon what the documentation supports, which can differ greatly even with the same diagnosis. A patient with a cough, runny nose, and fever may have other chronic conditions, taking the complexity quite high, or the patient may simply have a common cold, which would make it lower.

Consider the following two encounters:

Patient 1: This established 2-year-old female presents with cough, nasal discharge, and fever. Cough onset was one week ago, has gotten worse over time, and has been nonproductive. Nothing relieves the cough as yet. Maximum fever temperature was 102 degrees Fahrenheit for three days, but it has resolved. Acetaminophen helps.

Her parents both smoke in the home. The patient has no known allergies. Patient has a history of otitis media.

ROS:  Constitutional positive for fever, HEENT positive for nasal congestion and rhinorrhea, respiratory positive for cough.

Exam: Constitutional: Patient appears well-nourished, happy, and well-developed, with no distress noted. Ears: Right ear shows a normal tympanic membrane; left ear shows tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear, mucous membranes moist, and no oral lesions are noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy is noted. Respiratory: Normal to inspection. Lungs clear to auscultation bilaterally. Normal respiratory effort is noted. Cardiovascular: Regular rate and rhythm, with no murmurs. Abdomen: Soft, non-tender, and non-distended.

Assessment: Acute suppurative otitis media without spontaneous rupture of ear drum, left ear (H66.002). Prescribing amoxicillin oral suspension to be taken twice a day for ten days.

Patient 2: This established 7-year-old female presents with cough, nasal discharge, and fever. Cough onset was two weeks ago, is nonproductive, and has become gradually worse. Nothing relieves the symptoms. Nasal discharge onset was two weeks ago, and Dimetapp does relieve the symptoms. The fever’s onset was three days ago, and it occurs intermittently. The maximum temperature was 101 degrees Fahrenheit. Relieving factors include ibuprofen and rest. Associated symptoms include cough, nasal drainage, and nasal congestion. Ibuprofen was given at 9 a.m.

The patient has a history of asthma but has no known allergies. She lives with her parents and her older brother in a smoke-free home.

ROS: HEENT positive for bilateral otalgia and rhinorrhea but negative for pharyngitis. Respiratory positive for cough, wheezing. Constitutional: Positive for fever. Gastrointestinal: No vomiting.

Exam: Constitutional: Patient appears well-nourished and well-developed with no acute distress noted. Ears: Right tympanic membrane erythematous, left tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear with palate intact. Mucous membranes are moist with no oral lesions noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular, or axillary adenopathy noted. Respiratory: Normal to inspection. Lungs bilateral expiratory wheezes with slightly prolonged aspiration, symmetrical air exchange, without rhonchi or rales. Cardiovascular: Regular rate and rhythm with no murmurs, gallops, or rubs. Abdomen: Soft, non-tender, and non-distended, with no organomegaly noted and no masses. Skin: no ulcerations and is normal temperature. No swelling or discoloration. Neurological: Alert and responsive.

Assessment: Acute suppurative otitis media without spontaneous rupture of ear drum, bilateral (H66.003). Unspecified asthma with (acute) exacerbation (J45.901). Begin using albuterol every four to six hours as needed. Prescribe prednisolone for five days, amoxicillin for ten days. Follow up if worsening or if fever persists.

Clearly, even though the patients in both scenarios present with the same signs and symptoms, and the histories in both scenarios are detailed, the extent of the examination, the number of diagnoses, and the risk of complications for patient 2’s asthma would place the exam level at comprehensive and level of medical decision making (MDM) at moderate complexity in this encounter.

This suggests that the pediatrician would be correct in assigning an E/M level of 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 …) for the encounter with patient 2, as the exam and MDM levels both rise to satisfy the number of components necessary for a level-four E/M service for an established patient.

For patient 1, however, the pediatrician performed an expanded problem focused exam. Moreover, the established history of otitis media would lower the MDM level to low complexity, lowering the overall E/M level to 99213 (… An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …).