Pediatric Coding Alert

Question: For the following chart note (which appears exactly as written without grammatical correction and spelling out abbreviations), I am planning on submitting 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity &Usually the presenting problem[s] are of low to moderate severity &) with 686.1 (Pyogenic granuloma) and 682.5 (Other cellulitis and abscess; buttock)? Using the CMS standard documentation worksheet, does the documentation support a level-three visit?

CC: Boil on Buttock.

Allergies: Ø

Meds used: Augmetin Bactrim; Finished Bactrim

DS 1 week ago; was better, now worsening.

Sick how long? 1 month off + on.

Others sick? Ø Hangnails; Ø friends or family.

HPI: recurrence of abscess; Ø fever; painful when pres-sure applied; some drainage; BM and urine OK; Ø streaks.

Pertinent Physical Exam:

GENERAL: Alert, nontoxic, no distress, well hydrated.

NODES: N: Inguinal ?

Abdomen: Soft, non-tender, no mass, no HSM.

Skin: Turgor OK.

GEN: WNL OTHER: Ø hangnails fingers; L of midline buttock with serosanguinous D/C; pressure nonfluctuant; + pilonidal opening Ø discharge from there.

IMP: granuloma and abscess buttock; I&D cultured; start Keflex, heat.

FU: surgical evaluation.

New Jersey Subscriber

Answer: The low complexity medical decision making provided in the documentation limits you to 99213. The detailed history, expanded problem focused exam, and low complexity medical decision making supports a level-three established patient office visit (99213 with 686.1).

Money-loser: By not including an additional CPT Codes , youre missing approximately $98 in revenue. You should also separately report the incision and drainage with 10060 (Incision and drainage of abscess [e.g.,carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furnuncle, or paronychia; simple or single), which has 2.72 relative value units, according to the 2009 Medicare Physician Fee Schedule. Link 10060 to the abscess diagnosis (682.5).

Because you have an extended review of systems (ROS) with four documented systems -- no fever (constitutional), BM and urine OK (GU), no streaks (integumentary), no allergies (All/Immuno) -- the chart note counts as a detailed history. With seven elements of history of present illness (HPI), you have an extended HPI, which requires four or more elements. Under chief complaint (CC), you have buttock (location). Then, listed under Meds Used and Sick How Long, you have better with meds, now worsening (modifying factors) and sick 1 month (duration) off and on (timing).

Elements entered under HPI include recurrence (could go to severity), painful when pressure applied (associated signs and symptoms), and some drainage (quality). You have complete past medical, family, social history areas (PFSH) which requires covering two of the three areas: description of medications used (medical), no hangnails (medical), no friends (social) or family sick (family).

The examination is expanded problem focused (up to seven systems). The physician examines the affected body area or organ system and other symptomatic or related organ system(s) and addresses a total of four body systems/areas: alert and nontoxic (constitutional), no distress (pysch), well hydrated; nodes (hem/lymph/immuno); soft, non-tender & (abdomen); turgor OK (skin).

Limited number of diagnoses and/or treatment options combined with no data reviewed and moderate risk gives you low complexity medical decision making. You have two points total for the number of diagnoses and treatment options: one point for each minor problem (granuloma and abscess). Theres no data reviewed. The prescription drug management puts the type of risk at moderate.