Pediatric Coding Alert

Learn what not to do by following this expert advice.

Upcoding. Downcoding. Missing or no documentation. Using the wrong codes. If you've ever encountered these problems when coding 99201-99205 (Office or other outpatient visitfor the evaluation and management of a new patient ...) or 99211-99215 (Office or other outpatient visitfor the evaluation and management of an established patient ...), you're not alone.

In 2014, in a report titled "Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010," the Office of the Inspector General (OIG) made the startling claim that "42 percent of claims for evaluation and management (E/M) services in 2010 were incorrectly coded ... and 19 percent were lacking documentation."

The report outlines the most significant problems in coding E/M services, but these five hints will help you avoid the top five E/M coding errors and keep your reporting on the straight and narrow.

Hint 1: Avoid upcoding (OIG: 26 percent of E/M coding errors)

"Ninety percent of the upcoding I see in my E/M auditing experience is due to insufficientdocumentation, not due to clinicians 'padding their invoices' for better reimbursement," says Jan Blanchard, CPC, CPMA, pediatric solutions consultant at Vermont-based PCC. So, for example, documentation for a level-four E/M service should contain a history that reflects the complexity of the pediatrician's decision-making process. "Ignorance of E/M documentation guidelines, especially for new patient visits," Blanchard concludes, "is usually the culprit in these cases."

Chip Hart, director of PCC's Pediatric Solutions Consulting Group in Vermont and author of the blog "Confessions of a Pediatric Practice Consultant," also adds a note of caution to coders using E/M calculators in electronic health records (EHRs). "Coders," he warns, "should not trust a computer to make E/M decisions or use an EHR to auto-populate big portions of the chart note. This can create inflated and inaccurate notes thatlead to artificially complex-looking records."

Hint 2: Avoid downcoding (OIG: 15 percent of E/M coding errors)

Scenario: Your pediatrician diagnoses a newborn patient with K21.9 (Gastro-esophageal reflux disease without esophagitis) and asks you to bill a level-two E/M encounter because "it only took me five minutes to figure out what was going on." Coding this way, based simply on the time spent deliberating, is another mistake, according to Blanchard.

"While it may be true the diagnosis only took five minutes, the experience behind the thinking, questioning, and certainty for the diagnosis, and the time spent reassuring that newparent and explaining the course of care are also at play there," she says.

Instead, Blanchard argues, you should base your E/M coding either on the information gathered, the diagnosis, and the decision made, or on time if more than 50 percent of the encounter was spent in counseling the patient or parent and the coordination of care.

Hint 3: Provide sufficient documentation (OIG: 12 percent of E/M coding errors)

The next most common coding error involves providing insufficient documentation to support the level of E/M service. "One insufficiently documented claim in our sample," the OIG reported, "was based on counseling and/or coordination of care. However, only the length of time of the encounter was documented in the medical record. The medical record contained no description of the counseling and/or activities to coordinate care."

So, once you make the decision to use time as a factor, you must state the actual amount of time spent in the total visit and then the percentage of that time spent in counseling/coordination of care. It's also important to state what kind of counseling your pediatrician provided. For example, if your pediatrician spends 35 minutes with a patient, and 20 of those minutes are spent in counseling concerning the child's weight, nutrition, and exercise habits, then you could legitimately bill for a level-four E/M service.

Hint 4: Provide documentation (OIG: 7 percent of E/M coding errors)

"In the age of EHR, there isno excuse for missing documentation," Hart argues. He goes on to point out that there is no end to the opportunities a clinician has to include relevant information collected, shared, and/or created at a visit. "Every practice should have an easy mechanism for automatically pushing details about services rendered to your billers," Hartadvises.

Hint 5: Choose the right code (OIG: 2 percent of E/M coding errors)

Though the OIG report notes that simple coding errors only make up a small percentage of problems in E/M coding, Blanchard notes that these errors are easily avoided by "keeping up with changes to the code definitions." She offers the example of the recent change in CPT^® code 90686 (Influenza virus vaccine, quadrivalent (IIV4), split virus, preservative free, 0.5 mL dosage, for intramuscular use). Prior to Jan. 1, 2017, the code contained an age restriction (3 years of age and older) and did not stipulate the dosage (0.5 mL).

"Any practice that did not adjust," Blanchard warns, "had the potential to improperly bill a flu vaccine administered on Jan. 1, 2017, or after, for patients less than 3 years old even if they received a 0.5 mL vaccine."

"Lots of practices," Blanchard continues, "fail to discontinue billing separately for vaccine counseling when a patient reaches the age of 18." She offers the example of 90460 (Immunization administration through 18 years of age ... with counseling by physician or other qualified health care professional ...) and 90461 (... each additional vaccine or toxoid component administered...) being used for patients ages 18 or older, which is incorrect.

(You can view the full OIG report at https://oig.hhs.gov/oei/reports/oei-04-10-00181.pdf).