Pediatric Coding Alert

There are three main areas in the Evaluation and Management (E/M) Services: examination, history, and medical decision-making. The more work you do in each of these areas, the higher you can code the visit, and the more you will be reimbursed for the visit. Gauging the complexity of medical decision-making is more of an art than a science; the pediatrician must make many judgement calls. The new E/M Services Documentation Guidelines, which took effect last month, but will not be enforced until July 1, 1998, add some criteria to help you decide which of four levels of decision-making to use: straightforward, low complexity, moderate complexity, or high complexity.
There are three elements which you must consider when deciding which level of decision-making to use for a visit. These elements are:

(1) the number of diagnoses you have to consider,

(2) the amount and/or complexity of data to be
reviewed, and

(3) the risk of complications and/or morbidity or mortality.

As in the previously existing guidelines:

Minimal number of diagnoses, data to be reviewed, and risk yields a straightforward decision-making (office-visit codes 99201 and 99202 for a new patient, and CPT 99212 for an established patient),

Limited number of diagnoses, data to be reviewed, and risk yields a decision-making of low complexity (office-visit codes 99203 for a new patient and 99213 for an established patient),

Multiple possible diagnoses and moderate data to be review and risk yields a decision making of moderate complexity (office-visit codes 99204 for a new patient and 99214 for an established patient), and

Extensive possible diagnoses, data to be reviewed, and risk yields a high-complexity decision-making (office visit codes 99205 for a new patient and 99215 for an established patient).

To qualify for a given type of decision-making, two out of the above three elements must be met. For example, if the number of possible diagnoses is extensive (high complexity), but the amount of data is limited and the risk of complications is low, the type of decision-making is low complexity.

The problem with decision-making is that its subjective. And it is particularly challenging for pediatricians. You have to be extra careful if youre a pediatrician because of the risks involved, says Carla McDonald, AAP senior policy analyst.

The new guidelines require you to document how you make your decision in the following way:

For each encounter, you must document an assessment, clinical impression, or diagnosis. This documentation may be explicit or implied in decisions regarding management plans. For a presenting problem with an established diagnosis, your record should state whether the problem is (1) improved, well controlled, resolving or resolved; or (2) inadequately controlled, worsening, or failing to change as expected. For a problem that doesnt have an established diagnosis, you can state the assessment or clinical impression in the form of differential diagnosis or as a possible, probable, or rule out diagnosis.

Document any initiation of or changes in treatment. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.

If you make referrals or request consultations, the record must note to whom or where the referral or consultation is made or from whom the advice is requested.

If you order, plan, schedule, or perform a diagnostic test or procedure at the time of the E/M encounter, you must document this. In addition, you must document when you review lab, radiology, and other diagnostic tests. A simple notation such as `WBC elevated or `chest x-ray unremarkable is acceptable, the guidelines state. Alternatively, the review may be documented by initialing and dating the report containing the test results. Also, any discussion of tests with the physician who performed or interpreted them should be documented. Any direct visualization and independent interpretation done by you should be recorded also.

If you need to obtain old records or additional history from other sources (e.g. family or caretaker), document this in the record. Any relevant findings from these sources must be documented as well. Also, if there is no relevant information, that must be documented. A notation of `Old records reviewed or `additional history obtained from family without elaboration is insufficient.

To determine risk, you must consider

(1) the presenting problem or problems,

(2) the diagnostic procedure or procedures, and

(3) the possible management options. The highest level of risk in any one of these three categories determines the overall risk (minimal, low, moderate, or high).

Examples:

minimal risk in terms of presenting problems are a cold, a urinalysis for a diagnostic procedure, and gargles in terms of a management option;

low risk are a simple sprain for a presenting problem, a pulmonary function test for a diagnostic procedure, and over-the-counter drugs for a management option;

moderate risk are a head injury with brief loss of consciousness for a presenting problem, lumbar puncture for a diagnostic procedure, and prescription drug management for a management option;

high risk are psychiatric illness with potential threat to self or others as a presenting problem, diagnostic endoscopies with identified risk factors for a diagnostic procedure, and drug therapy requiring intensive monitoring for toxicity for a management option.

Enforcement of New E/M Guidelines Delayed The Health Care Financing Administration (HCFA), the federal agency which administers Medicaid and Medicare, will not be enforcing the new Evaluation and Management Documentation Guidelines until July 1, 1998. Originally slated for enforcement beginning January 1, 1998, HCFA decided to issue the delay after the American Medical Association expressed concern that there wasnt enough time to educate physicians about them.