Pediatric Coding Alert

Question: On an electronic medical record (EMR), do I need to redocument the physical exam when I find a problem, such as otitis media (382.00), that requires no additional exam during a preventive medicine service?

New Jersey Subscriber

Answer: Because you are not really doing anything more on the exam, code the E/M based on the problem-oriented history and medical decision-making (MDM). Re-entering the physical examination element, for instance red bulging ear, will offer more solid documentation supporting separate payment for the standalone office visit. Claims reviewers and auditors can more clearly see the work involved if you re-document the physical exam, and can be especially helpful if you have to appeal the problem-oriented portion. Realize that you might use a lower level E/M service code than you normally would use for such a problem when you treat it on its own due to the preventive medicine service’s examination overlap, and not being able to count this under both E/M services.

Alternatively, if you spend more than 50 percent of the problem-oriented portion’s time on counseling and/or coordination of care, use time as the controlling factor when selecting the E/M service level for 99201-99215 (Office or other outpatient service ...). You should still put the history of present illness (HPI), MDM and any other problem-oriented documentation, such as total time versus counseling time and counseling topic, in a separate box. But you could keep the exam findings, for instance red bulging ear, bloody nose (784.7) or rhinorrhea (478.19), in the preventive medicine service’s examination portion. In this case, time alone would determine the problem E/M code selected.

For instance, in the scenario you describe, if you spent ten to twelve minutes discussing management options, such as over the counter medication versus antibiotic treatment, reviewing numbers of past infections and talking to the mom about possible ventilation tubes, you could code a level-three established patient (99213-25, Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of a procedure or other service) based on time plus the preventive medicine service (99381-99395). For the history, physical exam, and MDM alone, you would code 99212-25 with the preventive medicine code. If you treated the otitis media at a separate encounter, you might instead be at a level-three (99213).