Neurology & Pain Management Coding Alert

Substitute documentation criteria to justify a higher-level E/M

If you-re using the same standards to classify pediatric and adult evaluation and management (E/M) services, you may be undervaluing your efforts. Rethinking your history, exam, and medical decision making criteria can help you make the most of your work with your littlest patients.

Most often, neurologists use the Centers for Medicare and Medicaid Services (CMS) 1997 E/M documentation guidelines to assign appropriate levels for their specialty-specific services, says Sherry Wilkerson, RHIT, CCS, CCS-P, coding and compliance manager at CHAN Healthcare Auditors in Clayton, Mo. Based on this model, the more history and exam elements that you can check off, the higher your E/M level, and reimbursement, climb.

Challenge: While this bulleted checklist provides a concrete means of establishing E/M levels for new or established patients (99201-99205 or 99211-99215), it also contains several elements that are not applicable when evaluating young pediatric patients.
CMS itself recognizes this shortcoming and explains in its 1997 guidelines that the requirements -reflect the needs of the typical adult population.- It goes on to say, -Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area-the content of a pediatric examination will vary with the age and development of the child.-

Bottom line: You can use other appropriate exam elements in place of the specific bulleted items, and then count these toward establishing a visit's E/M level.

Learn more: You can access the complete 1997 guidelines at www.cms.hhs.gov/medlearn/emdoc.asp.

Expand Exam Options

To properly assess the level of a single-system neurological exam, you must meet the following criteria:

- Problem-focused: one to five elements

- Expanded problem-focused: at least six elements

- Detailed: at least twelve elements

- Comprehensive: all 25 elements

In other words, a comprehensive exam for a pediatric patient may be impossible without substituting certain tests.

Example: You perform all elements of a comprehensive neurological examination for a 10-month old child with the exception of gait examination and orientation to time, place, and person. However, you do complete a startle reflex test and measurements of cranial circumference. Mistake: Don't jump to a detailed examination because you can't check off each bulleted item.

Instead, make clear in your documentation that you performed the reflex test and cranial measurements in place of the specific, bulleted items due to the patient's young age. You should also make sure that any changes you make for pediatric patients are still relevant to the overall exam and age appropriate, says Barbara Cobuzzi, MBA, CPC, CPC-H, CHBME, president of CRN Healthcare Solutions in Tinton Falls, N.J.

While substituting exam elements is an option, don't be too quick to dismiss certain criteria. -Each age group has a certain level of speech and language,- states Patricia Amyx, CPC, MCS-P, of Neurologic Associates of Waukesha, LTD in Waukesha, Wisc. -I would suggest documenting what the child can or can't do compared to a child in the same age group without health issues.- Even the normal cooing of an infant or his nonverbal responses to language can be exam elements to monitor and record.

Include Mother's Pregnancy in History

When documenting an adult patient's history of present illness (HPI), the neurologist can identify up to eight factors: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
 
For an infant, however, you can also include details of the mother's pregnancy and the infant's status of birth, explains Amyx. Similarly, social and family history for a young child can entail information about family structure, congenital anomalies, and hereditary disorders in the family.

Obtaining this family and parental information may require significantly more time than what is generally needed for an adult patient. Additionally, a child cannot effectively verbalize the nature of his complaint or provide other guiding information to the neurologist.

Impact: All of these factors can escalate the time involved in patient counseling and the level of complexity in your medical decision making for a pediatric patient.

Remember, CMS permits you to use CPT's reference time as the determining factor in establishing an E/M level when patient counseling and coordination of care makes up more than 50 percent of the visit. The time that often goes into these exam features for a young child can boost an otherwise lower-level E/M--based on exam, history, and medical decision-making--to a more appropriate reflection of your work.

Example: You spend 25 minutes of a 65-minute visit trying to gain enough trust to complete an office-based neurological exam from a frightened two year-old patient, and then take another 20 minutes to explain the exam results to his parent. Because counseling and coordination of care comprised 45 of the total 65-minute new patient visit, you don't need to consider the level of history, exam, and decision making to code 99205 (Office or other outpatient visit-Physicians typically spend 60 minutes face-to-face with the patient and/or family).
 
To get paid for your time, record the time involved in counseling, along with the total E/M time, and what the counseling entailed, advises Cobuzzi.