Pediatric Coding Alert

When coding your practice’s charts, it can be easy to gloss over specific information that may not seem critical to the code selection—but this type of oversight could lead to big problems. Check out the following pediatric note submitted to Pediatric Coding Alert and see if you can spot where the coding went wrong.

Patient name: Jane Smith

Provider: Anna Caldwell, RN. Electronic signature can be viewed at the end of the note.

Code reported: 99391

HPI: This ten-week-old female presents for a copy of her medical records to give the health department, which is where she receives her immunizations. A two month well child visit was also performed. The child is doing well with no concerns. The child feeds well and is alert.

PFSH: The primary language in the patient’s home is English. She lives with both parents, who live together but are not married. The patient sleeps in her own crib in her parents’ room. She sleeps on her back for about four hours at a time. They live in a single family home in a suburban neighborhood. They use a municipal water source. The parents smoke but only outside. The patient has no siblings. The patient uses a car seat facing the rear. There is one dog in the home and the family uses smoke detectors. There is no pool on the property.

Pediatric Interval history: The patient is bottle-fed using Similac and consumes seven ounces per feeding, about every four hours. The patient is not on any medications and has no known allergies.

ROS is negative for decreased activity or fever. Negative for cough or dyspnea. Negative for constipation, decreased appetite, diarrhea, reflux, or vomiting. Immunology is positive for animals at home. There are no bowel or bladder concerns. The patient takes three bowel movements per day and has five or six wet diapers per day.

Physical Exam:

Constitutional: Nourishment is normal, overall appearance is normal.

Head/face: Anterior fontanel is open and soft, skull is normal.

Eyes: Right and left pupil are normal. Right and left conjunctiva are normal.

Ears: Right and left canal are normal. Right and left TM are normal.

Nose/mouth/throat: Right and left nares are normal. Mucosa normal. Palate/uvula normal. Tonsils normal. Oropharynx normal.

Neck/thyroid: Neck inspection normal. ROM normal.

Cardiovascular: Heart rate is regular, rhythm regular, no murmurs.

Abdomen: Normal on inspection. Auscultation normal. Anterior palpation normal. Abdominal tenderness: negative.

Assessment/Plan:

Routine child health exam (V20.2). The following items were discussed today: Opportunities for physical activity, establish bedtime routine, face to face contact, preparing for future immunizations, skin/nail care, sleep patterns, sleep positioning, smoke-free home and car, socialization with family, avoid honey or corn syrup, avoid putting to bed with bottle, formula review, discussion of avoiding solids until four to six months. Immunizations given at health department, shots up to date. Follow-up recommended at four months.

Spot the Problems

This chart is extremely well-documented, and the notes do justify 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual…). Unfortunately, however, that code cannot be reported for this visit.

Why not? The provider for this visit is a registered nurse, who cannot report the preventive medicine E/M codes even if the physician is supervising her. Since the provider of record is the RN, you must default this to 99211.

Revenue loss: The fact that the RN performed and signed this note means that you’re only entitled to the approximate $20 that 99211 pays, whereas you would have collected about $100 for 99391 if an NP, PA, or physician performed the service.

Red flag: In this situation, the parents needed a copy of the medical record to give to the health department where the baby’s immunizations are performed. It appears that the well child visit was performed while the child was there, but it’s not clear whether the nurse saw the records and prompted the parents to stay for a complete well child visit that was overdue or if the visit was scheduled. Assuming the former occurred, it’s possible that this child was initially seen by the RN and then triaged to the physician for the overdue well child exam, but since the nurse’s name is on the note and she signed it electronically, the documentation only supports 99211. It also raises concerns with a nurse providing services beyond her scope of practice.

If transfer occurs, document it: A transfer from a nurse to a pediatrician is common, but you must always document when this occurs and make sure that the pediatrician signs the note and documents his face-to-face service. If it’s not clear who performed the service, an auditor will default to the name on the record, which in this case is the RN