Wiki Urgent Care E/M for Pediatrics


Columbus, OH
Best answers
Having trouble with Urgent Care visits for diagnoses such as OM, URI, Viral illness, Croup/Cough, Strep Throat

HPI - usually has 4 elements
ROS - has 2-9
PFSH - either has medical history or statement that No PFSH related to present illness

Exam - templates are used that they have to fill in the results of the exam
With these templates they will have anywhere from 5-9 organ systems listed
For an acute uncomplicated illness such as one listed above would you allow a Detailed exam just because the template has so many organ systems? There are usually at least 2 bullets in 6+ areas but we use 1995 guidelines.

MDM - is generally low with symptomatic care, OTC medicine or sometimes a 1 time antibiotic.

Opinions as to whether you would give this a 99213 or 99214?

Second question...
HPI states patient is there for congestion, cough and ear pain
On exam the patient as a fever
The assessment is OM with a 1 time antibiotic, OTC for symptomatic care but nothing about the fever
Would you give the MDM a moderate due to the fever on exam?

Thanks for any opinions/help!! There are differing opinions between coders on these.
At a practice where I used to work we had similar disagreements among coders and providers over this same situation with our urgent care clinics. During one of our annual audits with an outside audit company, the advice that was given (and with which I agree) was that most payers will consider it a level 3 E&M visit when there is only a single problem addressed and a prescription written. Although 'prescription drug management' is listed as 'moderate' in the risk table, I think it's important to keep in mind the instructions on the use of the table that these are 'clinic examples rather than absolute measures of risk'. For common problems that are diagnosed during a visit without additional testing and treated with a single prescription without any required follow-up, it doesn't really qualify as drug 'management' and moderate risk is not appropriate. And from the payer/auditor perspective, billing these as level 4 simply based on the volume of documentation doesn't meet medical necessity. For a level 4, IMO, the documentation really needs to at least reflect some additional complicating factor, e.g. a co-morbidity or additional problem being considered, an uncertainty in diagnosis requiring testing or consultation, or an order for additional follow-up with a physician.
Just to add to my previous comment, the Appendix C of clinical examples in the CPT book is a good reference for these kinds of issues and can give you additional support and guidance on the levels that are appropriate for different types of clinical situations.
Complexity In Pediatrics

Something else to consider...

A fever of 102 is much different in a 6 week old than a 6 year old. Also, while a medication may be OTC for adults and older children, there is often no dosage listed for infants/toddlers. If that is the case, the medication is no longer OTC, it is now prescription. A good example would be ibuprofen. An adult can take 400 mg OTC, but may be prescribed 800 mg as a prescription. There are children's chewables available as well. There is nothing on the package indicating the dosage for an infant of under x months, but the MD may tell the parent to give "x" amount of the drops every 4 hours. While the medication can be bought OTC, the dosage is considered prescription.

Also to consider, determining a diagnosis in an infant or young child can be more complex than for an older child/adult due to lack of verbal skills, developing anatomy, etc.
Can you tell me where you can find that in writing that 800mg of ibuprofen is no longer OTC. Thank you
Found this very helpful

Re: Prescription Drug Management

Postby Shannon DeConda » Thu Jul 17, 2014 7:02 pm

Prescription drug management has to do with drugs that can only be attained through a physician order (prescription) and are managed by the physician. The physician assigns a liability and amount of responsibility to assess for patient risk when a patient receives these medications, therefore a higher level is warranted with moderate risk. Over-the-counter medications, even at a prescription dose, are still a lower level of risk based on the classification and management process of the medication. The fact that a prescription was written for an over-the-counter medicine is not enough to warrant it as prescription drug management. This also applies to medications where the insurance will pay if a prescription is written; the logistics of writing an Rx alone do not allow for the consideration of this drug as prescription management. Review the documentation content for an actual management process. If the provider gives the patient a prescription for Prilosec to "manage" their chronic upper gastric complaints, there is management involved and not merely script writing. Be sure to evaluate the records thoroughly and not just automatically give credit for all prescriptions written.

Per the NAMAS medical auditing tip by our team mate sara san pedro written on 6-13-2014

Thank you,
Founder & President of NAMAS