Pediatric Coding Alert

Tip: Split documentation to make calculations easier.

If lengthy patient visits leave you wondering when to bump your E/M code up to 99214 or 99215, use our real-life example from Mary Noahr, office manager for Birth and Beyond Pediatrics in Tulsa, Ok., to help make the call.

Scenario: Parents brought their child to the office for a 9-month well visit. Additional diagnoses from the visit include failure to thrive (FTT), established diagnoses of eczema and reflux, and feeding problems. The parents declined reflux medications and UGI (upper gastrointestinal) tests at earlier visits, and refused to see a dietitian. The pediatrician spent approximately 1 hour and 15 minutes total with the patient and parents. She documented spending 45 minutes on feeding/eczema discussions. Documented services include:

• Writing a prescription for eczema treatment
• Performing a complete physical exam and anticipatory guidance due to the well visit
• Discussion on FTT and eczema issues on a separate progress note.

Challenge: The physician wants to charge 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity) in addition to the well visit code. Remember, however, that the well visit E/M code includes much of the exam the pediatrician completed. Experts weigh in on whether you can code according to the physician's recommendation.

Plan Ahead With Separate Documentation

When you document complicated visits, think ahead to how your documentation can make coding easier. For example, in this scenario, document both parts of the visit separately (30 minutes for the well visit and 45 minutes for eczema and feeding education).

Here's why: Separating the standard well visit services from the additional education and care make it easier to track the amount of time associated with each part of the patient's visit. Documenting those details helps you code more accurately and explains the situation in case you're audited later.

Feel Confident With 99215, 99391

Although Noahr's physician wanted to report 99214 for the E/M service, he actually provided enough care to merit 99215 (Office or other outpatient evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity). "I absolutely would bill both the preventive visit and 99215," says Nancy Bishof, MD, a pediatrician in Lexington, Ky.

Explanation: The CPT descriptor for 99215 states that, "physicians typically spend 40 minutes face-to-face with the patient and/or family." The pediatrician's services clearly support time-based coding because the counseling and coordination of care for failure to thrive and eczema constitute more than 50 percent of the documented face-to-face time spent addressing the problems (45 of the total 75 minutes). Therefore,you can legitimately report 99215.

Don't forget: Submit 99215 with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Report the well visit with 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]).

Link Diagnoses for Each Condition

Complete your claim with the correct diagnoses for each aspect of the patient's care:

• Link V20.2 (Routine infant or child check) with 99391 for the well check
• Link diagnoses for the other conditions to 99215.

Diagnoses addressed and counseled for include 530.81 (Esophageal reflux), 691.8 (Other atopic dermatitis and related conditions) for eczema, 783.3 (Feeding difficulties and mismanagement), and 783.41 (Failure to thrive).