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E/M, Peds

  1. #1
    Default E/M, Peds
    Medical Coding Books
    Seeking guidance, Does this sound right. Auditing a physicians notes. The note reads to me, a 12yr old with new prob. Pharyngitis. No HPI, but we have Exam on TM. Documented with some detail. And lungs, also documented with some detail. With a prescription of Keflex. Does this qualify for a level four. Keep in mind this is an Establish patient.

    So we got: Establish Patient
    2 detailed body areas examined
    New Prob
    Prescription Drug given.

    Using the 1995 guidelines, do we come up with a level four.
    Need input.


  2. #2
    Greeley, Colorado
    Sounds more like an EPF exam. If you have no HPI, EPF exam and moderate MDM that looks to be a 99213 to me.

  3. #3
    I agree, 99213.

    I suppose you could argue that those 2 systems were detailed if you use 1995 guidelines, but you have to remember that medical necessity is the key.

    Medicare Claims Processing Manual, Chapter 12, page 33:

    "Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed."

    An otherwise healthy 12-year-old kid with pharangitis is not a level 4 type of visit in my opinion.


  4. #4
    Need more input, Dealing specificly with PEDS. What age range, and what DX's warrent a Level 4. Keep in mind, the documention is met for a level 4.
    Looking for a response like. Children from 2months to 8yrs of age, with a new prob. bronchitis, viral syndrome, gastroenteritis, warrent a level 4 when given a prescription.


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