Pediatric Coding Alert

Question: When a nanny brings a patient in and I cant obtain a comprehensive history, how should I choose an E/M level?

Connecticut Subscriber

 
Answer: First, if this is an established patient, only two of the three E/M elements of history, examination and medical decision-making are needed, and, second, you probably have a comprehensive history in your files.
 
The pediatrician should reference the history in the chart. For example, the nanny brings in a child with vomiting (787.0x), with a history of gastroesophageal reflux (530.81). Reference the history and the dates of service reviewed. That will give enough documentation for a comprehensive history for the visit.
 
If the patient is new, perhaps visiting the area, and there is no parent (or the separated father, who does not recall any vaccination history, for example, brings the child in), a comprehensive history will probably be unobtainable. Medicare has a rule that allows history to be considered in determining the E/M level of a comatose patient. Some coders use the rule for non-English-speaking patients. Do not use the rule for patients who are simply too young to talk.

  You Be the Coder and Reader Questions answered by Teri Salus, AAP; Thomas Kent, CPC, CMM, Kent Medical Management, Dunkirk, Md.; Charles J. Schulte III, MD, FAAP, AMA CPT advisory committee, pediatrician, Sterling, Va.; and Richard H. Tuck, MD, FAAP, founding chairman, AAP coding and reimbursement committee, pediatrician, Zanesville, Ohio.