Urgent Care E/M for Peds


Columbus, OH
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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.


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Coding for pediatrics

I have the same question. Did you get a response? With EMR and the use of templates, every visit could potentially be a level 99214. I'm thinking the code should be based on the reason for the visit and medical decision making. Your thoughts?


True Blue
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I agree that if the history and exams are largely populated by template then the reason for the visit should play a role in the code selection. I've been told by professional auditors that many payers use a rule of thumb that a visit involving one uncomplicated problem and one prescription should be coded as a level 3. I generally agree with this - a level 4 visit should usually either involve multiple problems, or a single problem that requires some kind of additional testing or workup, or which poses enough risk that there is required follow-up. Of course, each note has to be taken on a case by case basis.