Pediatric Coding Alert

Hint: E/M format may not matter to an auditor, as long as the information is there.

Your practice probably reports E/M codes more than any other service, but knowing whether you’re reporting these codes correctly is paramount to collecting the (remove) that doesn’t mean you never have questions about how to report these services. Read on to check out six of the most frequently-asked questions on these commonly-billed codes.

Know Who Counts As ‘Established’ Patient

Question 1: Our pediatrician saw a newborn in the hospital and reported both 99460 (Initial hospital or birthing center care, per day, for evaluation and management of normal newborn infant) and 99462 (Subsequent hospital care, per day, for evaluation and management of normal newborn) as well as 99238 (Hospital discharge day management; 30 minutes or less) during the baby’s hospital stay. The following week, the patient presented to our office for preventive medicine services. Which code should we report for the office-based visit?

Answer 1: Because the pediatrician provided face-to face-services in the hospital, the patient would be considered established in the office (even though it is the patient’s “first” visit to the office). This would support billing 99391 (Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant [age younger than 1 year]) or an office visit for a post-hospital follow up. These visits are typically used to ensure that the baby is not jaundiced, is eating well and there is no heart murmur. Billing an office visit (established) 99212-99215 would be appropriate for this type of visit.

Reminder: You have to keep the “three-year rule” in mind for new patients. CPT® says that a new patient is one who has not received any professional face-to-face services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.

Does E/M Format Matter?

Question 2: Our pediatrician reported established patient office visit code 99213, but the only note in the chart is a letter back to the referring doctor detailing the patient’s condition. He insists that this is the way he has always done things, and there has never been a problem before. Is he correct that we can bill this claim without using the standard progress note?

Answer 2: Yes he is. The format of a standard E/M progress note is typically recommended, but not technically required by insurers, so a letter could be allowable, depending on what information you can find in that letter. Is there a chief complaint, review of systems, medication reconciliation, physical examination, and other similar documentation in the letter that supports 99213? If so, then it should hold up as documentation of the patient’s visit.

If, however, the letter simply states, “Thank you for referring Aidan Smith. I concur with your assessment of asthma and have recommended medication,” then you won’t meet the criteria for 99213 because you don’t have enough information (history, exam, and medical decision-making) to support the code.  

New Patient Rules Are Tricky

Question 3: We found several instances where our physician saw a new patient but didn’t document the minimum levels of history required (he either documented no chief complaint or no HPI) to bill any new patient office visit codes (99201-99205). What can we report in circumstances like this?

Answer 3: Unfortunately, you can’t report a new patient code without a history. Review the brief HPI information the physician documented to determine if the statement contains both elements of a CC (chief complaint) and History of Present Illness (HPI). The doctor must document the HPI, exam (with the exception being vitals, which an ancillary staff member can document), and the Medical Decision Making (MDM). You need documentation of all three key components (history, exam, and MDM) to support even the lowest new patient level E/M code.

If you truly have no HPI documentation, you cannot submit a claim with the new patient E/M codes (99201-99205). Help educate your providers on the importance of clear E/M documentation. The HPI is a vital part of the patient record that documents the reason why the patient is seeking care and the circumstances surrounding the problem that led up to and includes the present status and any changes since the patient’s last visit. If a physician routinely omits the HPI, you’ll be hard pressed to establish medical necessity for many patient encounters.

Exception: The initial visit can be coded based on time if more than 50 percent of the face to face visit is spent counseling or coordinating care, and it’s documented in the medical record.

Can You Rely on EMR Codes?

Question 4: The pediatrician is a very thorough documenter and often treats very sick patients. Because he documents his EHR so well, almost all of his cases qualify for 99214s and 99215s. Since the documentation supports his code selections, is this acceptable?

Answer: 4: Not necessarily. Your electronic health record will most likely offer an E/M code suggestion at the end of each visit--but that doesn’t mean you can use that to justify all high-level codes.

Several practices have told Pediatric Coding Alert that their physicians “thoroughly document” the History and Physical Exam elements for all conditions, leading to high-level codes, even if the Medical Decision Making (MDM) doesn’t support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three criteria (History, Exam, MDM).

Reality: You must have medical necessity to report high-level codes—you can’t simply perform the requirements of these codes to drive a higher E/M level.

Are Vitals Imperative?

Question 5: A mother brought her daughter to our office after hours, when the nurse was gone for the day. The doctor saw the child, but he didn’t take any vitals. He documented the office visit for this “no appointment add-on” service, but our office manager said that we cannot bill for the encounter since no one took vitals. He did document everything else (history, exam, medical decision making). Is the office manager right?

Answer 5: Not necessarily—although they are almost always documented, vitals are not required in order to bill an E/M visit. Vitals are important-- and usually the norm -- but really are just another component of the exam. Since the physician documented the history, exam, and level of medical decision making, he should have sufficient notes for the practice to choose the correct E/M code.

Don’t Jump to Report E/M Codes

Question 6:  Our nurse gave a patient an allergy shot. Which E/M code can we report with it? The nurse circled 99211 but we aren’t sure if it’s applicable here.

Answer 6: You can’t bill 99211 for just an allergy shot or vaccination. For allergy shots, you should code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) for a single shot or 95117 (...2 or more injections) for two or more shots.

If the billing provider supplies the allergy serum, then you should bill for the serum at the time the provider makes the new serum. For vaccinations, bill the vaccine separately and use 90471 (Immunization administration [includes percutaneous, intradermal, subcutaneous, or intramuscular injections]; 1 vaccine [single or combination vaccine/toxoid]) for a single injection, 90473 (Immunization administration by intranasal or oral route; 1 vaccine [single or combination vaccine/toxoid]) for a single nasal/oral vaccination, or +90472 for each additional vaccination that is IM, subcutaneous or intradermal. If giving an IM and Oral vaccine at the same time use the each additional oral vaccine code 90474 instead of the 90473.

Note: If the nurse provides a separate, medically necessary E/M service-- for example, if the patient has a separate illness or a reaction to the injection that requires a separate evaluation -- then you can separately bill for these services using 99211 with modifier 25 appended. Make sure the documentation supports these services.