Pediatric Coding Alert

You should consider risk only a part of level selection.

Your pediatrician's level won't hold water unless you consider two MDM elements and two E/M components when scoring an office visit involving moderate risk.

The level of risk is only one part of medical decision-making (MDM). To determine the level of MDM, you will still have to score the "Number of Diagnoses or Treatment Options" (NDO) and the "Amount and/or Complexity of Data Reviewed" (ACD). These items, plus the highest risk, comprise the three elements of medical decision-making.

Example: A patient has allergic rhinitis that's usually controlled with Allegra-D but weather changes trigger the patient's allergies, which precipitates her sinusitis. The patient's sinusitis is a new problem to the pediatrician and he plans no additional work-up and orders no tests. The patient, an adolescent, gives her own history. The pediatrician has previously treated the patient's allergies and writes her a prescription telling her to fill it if after she finishes the samples provided. She decides the Xyzal is decreasing her sinusitis and allergic rhinitis exacerbations.

Under NDO assign the sinusitis three points for a new problem with no work-up and the allergic rhinitis one point for an established, stable problem.

You would give no points under ACD. The teenager gives her own history, and the physician orders no tests.

The four points for diagnoses counts as extensive and no data equals minimal or low. Here's how these scores would appear on the "Final Result for Complexity":

The Highmark auditing score sheet, the standard one CMS issues, instructs you if no column contains two or three circles to "draw a line down the column with the second circle from the left."

Drawing a line down the column with the second circle from the left gives you moderate complexity MDM. A level-four established patient office visit (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity ...) contains MDM of moderate complexity.

Look at the Big Picture

You would still have to verify the history and examination portions of the encounter. The above encounter involves an established patient, which requires two of the three key components. Some possible solutions include:

* If the pediatrician performed and documented a medically necessary detailed history or examination, the visit would be 99214.

* An expanded problem-focused history and expanded problem-focused exam with moderate complexity MDM would support 99213.