Orthopedic Coding Alert

You may be able to substitute notes to justify a higher-level E/M.

As summer time rolls around and kids play outdoors, your orthopedic practice may see more pediatric patients, but be careful. Orthopedic surgery practices that use the same E/M standards for pediatric and adult patients may be selling themselves short. If you rethink your history, exam and medical decision-making criteria, you can make the most of your work with your youngest patients. 

Generally, orthopedic surgeons use the Centers for Medicare & Medicaid Services 1997 E/M documentation guidelines to assign appropriate levels for their specialty-specific services. Based on this model, the more history and exam elements that you can check off, the higher your E/M level — and reimbursement—climbs.

Challenge: Although 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.

Expand Exam Options

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

• Problem-focused: one to five elements
• Expanded problem-focused: at least six elements
• Detailed: at least 12 elements
• Comprehensive: all elements identified by a bullet.

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 musculoskeletal examination for a 10-month-old child who has a potential bone malformation. However, you are unable to complete the gait examination and orientation to time, place, and person. You perform 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 are age-appropriate, says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

Although substituting exam elements is an option, don’t be too quick to dismiss certain criteria. Because each age group has a certain level of speech and language, you should document what the child can or can’t do compared to a child in the same age group without health issues. Even an infant’s 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 orthopedic surgeon 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. 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 insurers generally expect for adult patients. And a child cannot effectively verbalize the nature of his complaint or provide other guiding information to the orthopedic surgeon.

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 make up more than 50 percent of the visit. With kids or even teenagers, the patient counseling can be, and usually is, parent counseling. 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 musculoskeletal exam from a frightened 2-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 report 99205 (Office or other outpatient visit .... Typically 60 minutes are spent 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, Cobuzzi says.