Pediatric Coding Alert

Question: My provider saw an established child with an earache. The provider ordered and administered an in-office test, which showed there was an infection. The provider prescribed ear drops. Does that qualify my provider for a 99214 (Office or other outpatient visit… and moderate level of medical decision making)?

AAPC Forum Participant

Answer: Based only on the information provided, this encounter sounds more like grounds for 99213 (Office or other outpatient visit for the evaluation and management of an established patient… and low level of medical decision making…). Here’s how to calculate it.

The CPT^® Evaluation and Management (E/M) Outpatient Guidelines explain that for you to choose an E/M code based on medical decision making (MDM), the encounter must satisfy two of the three elements in the table. For Number and Complexity of Problems Addressed in the abovementioned encounter, there is an acute uncomplicated illness (low level). For Amount and/or Complexity of Data, there is one test that was ordered, administered, and reviewed (low level). For Risk of Complications, the provider prescribed drops (moderate). This means you’d report the encounter as 99213.

The guidelines also mention that time can be used to level and encounter, but the provider’s documentation would need to adequately explain the 30-39 minutes spent evaluating and managing the patient in order to justify reporting 99214.