Pediatric Coding Alert

Question: Our pediatrician saw an established patient with severe chronic allergies. The patient did not present with any symptoms currently, but the doctor documented a detailed history, a detailed exam, and low complexity decision making and circled 99214. Is this possible for a visit where he was just managing a previously-diagnosed condition?

Maryland Subscriber

Answer: If the documentation meets the criteria for 99214, you can report it. According to CPT® rules, you need two out of three elements to support an established patient E/M service. In this case you have a detailed history and a detailed exam, which support a level-four office visit code, as long as there is medical necessity for a level-four established visit.

Important: Medical necessity must support the level of your coding. With this patient, due to his severe chronic allergies, the physician would be justified in performing a detailed exam and detailed history even though his medical decision-making (MDM) is only low level.

If the nature of the presenting problem won't support a higher-level E/M service, you should not inflate your coding for the service just because the physician documented an unnecessary high-level history and exam. Medical necessity is the overriding factor that should determine the service level.

Remember: MDM does not equate to medical necessity. Just because MDM is low for an established patient, that does not mean there is not medical necessity for the physician to perform (and bill) a level-four visit. Because of the way you must calculate MDM -- using the number of diagnostic options considered, using the number of tests ordered, and/or using the table of risk -- the MDM does not have a one-to-one equality for medical necessity, in particular for a patient who happens to be exhibiting control for previously uncontrolled chronic disease symptoms.