Orthopedic Coding Alert

Because pediatric patients usually don't boast "comprehensive" medical histories, practices are often frustrated that they cannot report level-four and -five E/M codes for these services. If your pediatric visits are time-consuming, however, you can base your E/M level selection on the amount of time you spend with the patient if the encounter meets CPT's criteria.

Suppose a 12-year-old patient twists her ankle while playing kickball. She presents to the pediatric orthopedist with a swollen, bruised ankle. The orthopedist evaluates the patient and requests an x-ray. The x-ray is negative for fracture, so the orthopedist prescribes ice packs and acetaminophen and asks the patient to return for additional evaluation if the pain persists for more than one week.

The patient's parents ask a series of questions about the patient's ability to exercise, use stairs, attend school, etc., requiring the orthopedist to spend a total of 65 minutes in the examining room: 30 minutes evaluating the patient and reading the x-rays, and another 35 minutes discussing the patient's condition with the parents.

You would probably assign a level-three new patient E/M code (99203) for this visit because the patient's history of present illness (HPI) would not rate "comprehensive" (as required to bill 99204 and 99205). Because you spent more than half of the visit counseling and coordinating care with the patient's parents, however, you can use time as the key factor to increase your E/M level.

"If you counsel the patient or the patient's family for more than half of a 65-minute new patient visit, then you should report 99205, since CPT suggests that the physician would spend about 60 minutes with the patient to bill this code," says Donna Fernandez, owner of Fernandez Billing Associates.

Pediatric patients often require more time in counseling and coordination of care than adults simply because pediatric patients'parents are very concerned. What you want to avoid, however, "is upcoding all of your E/M services because you talked at length with the parents or taught them how to apply splints or braces," Fernandez says. "An auditor would frown on any practice that bills most of its E/M codes based on time."

She recommends that orthopedists maintain pristine documentation that delineates the time they spent evaluating the patient versus the amount of time they spent coordinating care.

For instance, document the evaluation and examination portion of the visit as usual and add a note to the chart that says, "Following 30-minute evaluation and x-ray analysis, I spoke with the patient's parents for 35 minutes regarding exercises that the patient may perform, her ability to attend school, signs to look for that may indicate additional injury, and dosage of NSAIDs to administer."