Pediatric Coding Alert

Coding alert 1: “In this scenario, you would bill the E/M with the nosebleed, attaching modifier 25 [Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service]. You would bill the foreign body removal additionally, using 30300 [Removal foreign body, intranasal; office type procedure]” along with R04.0 (Epistaxis), suggests Donna Walaszek, CCS-P, billing manager, credentialing/coding specialist for Northampton Area Pediatrics, LLP, in Northampton, Massachusetts.

Answer 2

Number and complexity of problems addressed: Moderate. The asthma diagnosis qualifies as a chronic illness with exacerbation.

Amount/complexity of data reviewed and analyzed: Limited. This time, in addition to the independent historian, the pediatrician has ordered and reviewed one unique test. However, as this encounter does not require two of the three items from category 1, or meet category 3, “this MDM element of the encounter still only rises to the level of limited,” Walaszek argues.

Risk of complications or morbidity: Moderate due to the prescription drug management.

Level of MDM: Moderate. Based on the two moderate elements of problems addressed and risk of morbidity.

E/M assigned: As the patient is new to the practice, this would result in an office/outpatient E/M of 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires … moderate level medical decision making …).

Answer 3

Number and complexity of problems addressed: Low/ High. This is a gray area in the new guidelines. If the pediatrician views the patient’s depression as “a psychiatric illness with potential threat to self or others, then you would assign this element of MDM as high,” Walaszek believes. However, “if the patient states she will not hurt herself and has agreed that she will call in for any help should she get more depressed or have an anxiety attack,” your pediatrician could view this element as low, argues Holle.

Amount/complexity of data reviewed and analyzed: Limited. This is based on the administration and interpretation of the PHQ.

Risk of complications or morbidity: Minimal/ Moderate. Again, this is a gray area. “As no additional testing or treatment is involved, this would be minimal,” says Holle. However, “as the pediatrician discussed the option of prescription medication and counseling, this could fit the criteria of ‘the need to initiate or forgo further … treatment’ per CPT^® guidelines,” says Walaszek

Level of MDM: Straightforward/Moderate. With the ambiguity over the complexity of the patient’s condition and the risk of complications, assigning the level of MDM to this encounter is difficult, and MDM could be assigned at the lowest or highest level depending on provider documentation.

E/M assigned: The different levels of MDM mean you could conceivably code this encounter as a 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … straightforward medical decision making …) or a 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires … moderate level medical decision making …).

Coding alert 2: The better option in coding this E/M encounter might be to code based on time, both Holle and Walaszek believe. As we know that the encounter’s total time is 31 minutes, this encounter is more easily coded as a 99214.