Pediatric Coding Alert

by Thomas Kent, CMM, CPC, is principal of Kent Medical Management, a coding and practice management consulting firm based in Dunkirk, Md. Kent was the office manager for his wifes pediatric practice for five years and has been a featured speaker for pediatric coding conferences and seminars throughout the country.

Documentation is now a matter of compliance. That means that improper documentation can be fraud, a violation of the law which can lead to fines and even jail. Chart auditors, like myself, help protect physicians by teaching them how to document completely and accurately. The following is a list of documentation problems which are fairly common in pediatrics, where evaluation and management (E/M) services are the main codes billed. Correcting these problems will greatly improve your documentations support of the level of service billed.

1. Incomplete review of systems (ROS). The CPT system has identified 14 different systems (constitutional, eyes, ENT, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic) which the pediatrician may discuss with the patient (or parent) during the question and answer portion that begins the office visit. To have a complete ROS, by CPT definition, you must document at least 10 of these 14 systems. Many times I have had to reduce a CPT 99205 (office or other outpatient visit for the E/M of a new patient) to 99203 or a 99223 to a 99221. Although the patients case and the physicians work clearly supported the higher levels, the coding was reduced because the physician only documented the review of seven systems. There are two simple methods to avoid this unnecessary problem: (a) If the parent completes a history form when registering, the physician can sign and date the patients history and then reference the same in the physicians note; (b) Writing the phrase all others negative at the end of your review of two or more systems will, by definition, support a complete ROS.

2. Incomplete past, family or social history (PFSH). To support a comprehensive history, the documentation needs to show at least one question each for past, family and social history. Alternatively, you can say the family history or social history is non-contributory.

3. Lack of cross-references. Whenever the physician goes back to review a prior record, the original note should be referenced in the current note. This is helpful in two ways: (a) The referenced note is now included in the current history, and (b) Referencing the physicians own prior note is worth one point in medical decision-making and referencing another physicians note, such as records from the previous primary-care physician, is worth two points. (See box on page 60 for explanation of the point system.)

4. Not listing status of established problems. In determining medical decision-making, each established problem that is improving is worth one point while each established problem that is not improving or worsening is worth two points. An auditor cannot derive the better vs. worsening status of a problem from the body of the note as a physician might be able to do. It is helpful for the physician to state that a problem is no better or worsening. When the documentation is not clear on this issue, the auditor will assume the problem is improving or stable.

5. Not explicitly stating when adolescent gynecological visits are performed. When conducting an adolescent gynecological exam, the pediatric physician will probably not examine eight different organ systems; therefore, the doctor will be stuck with a detailed, rather than a comprehensive, level of exam. Yet these can be difficult and lengthy exam sessions. The pediatrician can finish the exam documentation with the statement this is a comprehensive adolescent gynecological exam. By the 1995 CPT system this can now be counted as a comprehensive level of exam.

The 1995 system is actually rather vague on what constitutes the various levels of exam. The eight organ systems criteria is great for multisystem problems, but does not address single-system problems. Yet a single- system exam can be very extensive. Therefore, it is acceptable for the physician to define when a comprehensive exam has been completed. This is done by simply stating: This is a comprehensive pediatric exam. The vagueness of the 95 system is actually why the 97 system was created, and because that is so fraught with problems, most pediatricians continue to use the 95 system. I would not expect a pediatrician to need the comprehensive statement often. Pediatricians frequently examine eight or more organ systems, which is comprehensive by definition, and pediatricians infrequently examine one organ system comprehensively. The adolescent gynecological exam is an exception. For diagnosis codes, some physicians like to use V25.01 (prescription of oral contraceptives), but this can create problems if the young lady wishes to keep the issue confidential. I recommend V72.3 (gynecological examination).