Pediatric Coding Alert

Review this documentation and determine how you’d code it before you read the solution.

Even pediatricians who are in a hurry to get to the next patient are required to spend a bit of time on the history portion of the E/M documentation—or could risk forfeiting E/M pay. As part of our E/M series, we’ll be sharing an E/M coding vignette each month to test your E/M coding finesse. See if you can spot the problems with this pediatrician’s note.

Code reported: 99212

Chief complaint:None recorded.

Problems: None recorded.

Allergies: Allergic to all penicillin

Medications: None other than daily multivitamin

Social history: This 14-year-old patient is a student in the ninth grade. She rides her bike for exercise and takes gymnastics once a week.

Family history: The patient’s parents are alive and healthy. Her maternal grandmother has diabetes and her maternal grandfather had melanoma but recovered. Her father is adopted and she therefore does not history on her paternal grandparents.

Review of Systems: None recorded.

Physical exam: None recorded.

Lab results: Urinalysis dipstick: Leukocytes negative; Nitrite negative; Urobilinogen: 0.2; Protein: Trace; pH: 6.0; Blood: Negative; Specific gravity: 1.030; Ketone: Negative; Bilirubin: negative; Glucose: negative; Appearance: clear; Color: Pale yellow.

Basic metabolic panel: Glucose: 98; BUN: 12; CA: 9.0; CRE: 1.0; NA: 140; K: 3.9; CL: 103; TCO2: 24.

Assessment/Plan: General medical examination (v20.2, Health supervision of infant or child; routine infant or child health check)

Dipstick urinalysis

Basic Metabolic panel

CBC w/diff

Venipuncture 1

Did You Spot the Problems?

Unfortunately, this chart cannot be coded with any E/M service code as it stands, since the only element documented is the medical decision-making section. The physical exam section is blank, and the history is missing a chief complaint. The reason for a medical visit cannot be inferred, thus making this chart non-codeable.

Chief complaint primer: The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the E/M encounter. It is typically stated in the patient’s own words. An example would be a “sports check-up,” or “burning on urination.”

Although some coders were trained to only look for a chief complaint in one particular section of the documentation, that is inaccurate. The chief complaint may actually be listed as a separate element of the history, or it may be included in the history of present illness (HPI).

Unfortunately in this case, the pediatrician did not record a history of present illness or review of systems either, leaving question as to the chief complaint.

Keep in mind: The missing HPI would be a problem no matter what service level you report, since every E/M service level requires an HPI of either brief or extended. According to the documentation guidelines for E/M services, the physician must document the HPI portion of the history, and history requires at least one element of the HPI. Further, you need documentation of two key components (history, exam, and medical decision making) to support an established-patient level E/M code. With a missing physical exam and history, this chart is not codeable.

Preventive code: Although a preventive medicine code might be considered instead of an established problem oriented E/M code, it would also require an age-appropriate history and physical examination, both of which are not provided in this documentation.

Solution: In this case, you’ll have to report only the laboratory services your practice performed, such as 80048 for the basic metabolic panel, 36415 for the venipuncture, 81002 for the dipstick urinalysis, and 85025 for the complete blood count with differential.