Pediatric Coding Alert

Select the appropriate code based on the documentation--not the specialty or diagnosis.

When it comes to an immunization or a urinalysis, you may know the standard codes for each service by heart. When you're evaluating codes for an E/M service, however, the issue isn't so clear-cut.

Consider this question submitted to Pediatric Coding Alert from a subscriber: "Which code should we report for evaluation of a cough, runny nose, and fever? We can't decide whether it should be 99212 or 99213--but the pediatrician actually marked 99214."

This question supports a common myth--that each type of diagnosis has a standard E/M code associated with it. However, your E/M code should be based upon what the documentation supports, which can differ greatly even with the same diagnosis. A cough, runny nose, and fever patient may have other chronic conditions, taking the complexity quite high--or he may simply have a common cold, which could be lower.

Consider these examples of visits that qualified for 99212, 99213, and 99214 so you can see the differences between the three:

99212: The patient is a 6-year-old girl who presents today with ear pain.

ROS: Constitutional: Negative for fever. HEENT: Positive for bilateral otalgia and rhinorrhea. Respiratory: Positive for cough. Gastrointestinal: Positive for vomiting.

Exam: Constitutional: Patient appears well-developed. Ears: Right and left tympanic membrane normal. Nose/mouth/throat: Nose and throat clear. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy noted. Respiratory: Normal to inspection. Lungs clear to auscultation bilaterally. Normal respiratory effort noted.

Assessment: Acute otalgia. Take acetaminophen as needed until symptoms subside. Call or return if condition worsens.

99213: This 2-year-old female presents with cough, nasal discharge, and fever. Cough onset was one week ago, and cough has been non-productive. It began as a "tickle in the throat" and has gotten worse over time. Context: Nothing relieves the cough as yet. Associated symptoms include cough, fever, nasal congestion and rhinitis. Maximum fever temperature has been 102F but it has resolved. The fever took place for three days. Acetaminophen helps.

The patient has a history of GERD and RSV. Her mother has asthma and diabetes. She lives with her father and mother and attends day care each day. Her parents both smoke in the home. The patient uses a front-facing car seat and has no known allergies.

ROS: Constitutional positive for fever, HEENT positive for nasal congestion and rhinorrhea, respiratory positive for cough but negative for wheezing. Weight, pulse, temperature, and blood pressure were recorded in the chart by Susan Jones, RN.

Exam: Constitutional: Patient appears well-nourished, happy, and well-developed, with no distress noted. Ears: Right ear shows a normal tympanic membrane, left ear shows tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear, mucous membranes moist, and no oral lesions are noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy is noted. Respiratory: Normal to inspection. Lungs clear to auscultation bilaterally. Normal respiratory effort is noted. Cardiovascular: Regular rate and rhythm, with no murmurs. Abdomen: Soft, non-tender, and non-distended.

Assessment: Suppurative otitis media (382.00). Prescribing amoxicillin oral suspension to be taken twice a day for ten days.

99214: This 7-year-old male presents with cough, nasal discharge, and fever. Cough onset was 2 weeks ago, and is non-productive. The problem has become gradually worse ever since her brother brought home a cough from school 3 weeks ago. Nothing relieves the symptoms. Associated symptoms include fever, nasal congestion, and rhinitis. Nasal discharge onset was 2 weeks ago and Dimetapp does relieve the symptoms. The fever's onset was three days ago and it occurs intermittently. The maximum temperature was 101 F. Context includes URI symptoms and sick contacts at home. Relieving factors include ibuprofen and rest. Associated symptoms include cough, nasal drainage, and nasal congestion. Ibuprofen was given at 9 a.m.

The patient has a history of asthma, but has no known allergies. She lives with her parents and her older brother in a smoke-free home.

ROS: HEENT positive for bilateral otalgia and rhinorrhea but negative for pharyngitis. Respiratory positive for cough, wheezing. Constitutional: Positive for fever. Weight, pulse, temperature, and blood pressure were recorded in the chart by Susan Jones, RN. Gastrointestinal: No vomiting.

Exam: Constitutional: Patient appears well-nourished and well-developed with no acute distress noted. Ears: Right tympanic membrane erythematous, left tympanic membrane erythematous. Nose/mouth/throat: Nose and throat are clear with palate intact. Mucous membranes are moist with no oral lesions noted. Teeth and gums are normal for age. Lymphatic: No abnormal cervical, supraclavicular or axillary adenopathy noted. Respiratory: Normal to inspection. Lungs bilateral expiratory wheezes with slightly prolonged aspiration, symmetrical air exchange, without ronchi or rales. Cardiovascular: Regular rate and rhythm with no murmurs, gallops, or rubs. Abdomen: Soft, non-tender, and non-distended, with no organomegaly noted and no masses. Skin: no ulcerations and is normal temperature. No swelling or discoloration. Neurological: Alert and responsive.

Assessment: Suppurative otitis media (382.00), asthma exacerbation (493.92). Begin using albuterol every four to six hours as needed. Prescribe prednisolone for 5 days, amoxicillin for 10 days. Follow up if worsening or if fever persists.

Look at Your E/M Coding

Going forward, review your coding choices to confirm that clinicians aren't choosing the same level of service for every claim relating to the same diagnosis. For example, if the pediatrician primarily sees patients with cystic fibrosis and charges 99215 for every visit because cystic fibrosis is a high-risk diagnosis, she is coding incorrectly. Some visits may require less documentation and intensity even if the diagnosis is complex, while others might require more than expected, depending on the patient's other conditions.

The bottom line: The answer to which E/M code to report lies in the documentation, and nowhere else. Always code to meet your documentation.