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 [...]