Pediatric Coding Alert

See if you agree with our experts’ decisions.

You have probably coded more evaluation and management (E/M) services for patients with acute otitis media (AOM) than you care to count.

So, we put together this AOM case study to make sure you’re doing it all by the book. We also invited two experts in the E/M field to give you their insights and help sharpen your decision-making processes when you code for this condition.

The Case

A 2-year-old established female patient has been suffering from right ear pain constantly for the last two days. Her mother reports that the condition has been accompanied by a low-grade fever, and the pain has been quite severe at times. The mother also reports that the child’s father smokes cigarettes in the house.

The pediatrician notes that the child has no known drug allergies. Upon exam, the pediatrician notes that the child has clear lungs, with no signs of a cough, a sore throat, or shortness of breath. There is no discharge or drainage from the child’s left ear, but the right tympanic membrane is bulging and erythematous. The child is alert and active and is running a fever of 100.4.

The pediatrician provides a diagnosis of AOM, prescribes an antibiotic, and tells the mother to return for a re-check if the patient does not improve in the next 48 hours.

Know Your Elements to Narrow Down the E/M Level

History of present illness (HPI): You only need four elements of the patient’s current illness to justify an extended HPI — the highest level possible. The most obvious in this case are “the right ear for location, constant pain for timing, the last two days for duration, and severe for severity or quality,” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania.

Review of systems (ROS): In this situation, the pediatrician has not documented a review, but two elements could be counted in this category. The patient’s fever could be counted as constitutional system, and the patient’s no known drug allergies [NKDA] could be counted as a review of the allergy/immunologic system.

This can create a problem in the way this scenario is levelled. “A common mistake some coders make is counting NKDA as part of the ROS, but it is always past history,” says Falbo. “I generally do not give credit in the ROS for NKDA,” agrees JoAnne M. Wolf, RHIT, CPC, CEMC, coding manager at Children’s Health Network in Minneapolis. “I count that as past medical history, too. But some auditors do count NKDA as a system in ROS,” Wolf notes.

We’ll come back to that in a minute, as how you count the ROS in this encounter will change the E/M level.

Past family and/or social history (PFSH): Here, you can count at least one element (the patient’s father’s habit of smoking). But even if you count NKDA here as a second element, the PFSH only rises to the level of detailed.

This means your history level is expanded problem focused at best, but more likely just problem focused.  

Exam: “With only three systems examined — constitutional, ENT, and respiratory — the exam is expanded problem focused,” says Wolf.

MDM: Assuming this is the first time the patient has presented with this particular problem, you can assign “3 points for a new problem,” according to Wolf. Additionally, as there is no workup, no labs and “a moderate risk due to prescription drug management,” according to Falbo and Wolf, MDM here rises to moderate complexity at most.

Putting it All Together

Depending on your interpretation, “this would give you a 99213 [Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …]” according to Falbo.

Why? As this is an established patient visit, you eliminate the lowest of the three qualifying key components, and the remaining two “must meet or exceed the stated requirements to qualify for a particular level of E/M service,” according to CPT^®. So, dropping the problem focused history as your lowest component, you are left with an expanded problem focused exam and moderate complexity MDM. The MDM may exceed the level for a level-three established patient E/M, but the exam level only meets the level. So, the encounter becomes a 99213 E/M.

However, if you count two elements in the ROS category (the fever and the NKDA), “the history component changes from problem focused to detailed, which would then change the overall visit level to 99214,” Wolf elaborates. That’s because the detailed exam and moderate complexity MDM have now met the levels for 99214.

Decide on the Dx

You no doubt zeroed in on H66.91 (Otitis media, unspecified, right ear) for a diagnosis code, as both of our experts did. But the provider could have gone much further and been more specific. In this case, the pediatrician in question “did not indicate the type of OM except that it was acute,” Wolf notes. Additionally, the provider “should have specified if it is acute suppurative otitis media without or without a spontaneous rupture of the ear drum,” Falbo adds.