Pediatric Coding Alert

Question: The risk management table lists prescription drug management as moderate risk. Does this mean I can code 99214 when an encounter requires an antibiotic?

Colorado Subscriber

Answer: Prescribing an antibiotic does not automatically mean you should code a level-four E/M service (99214, Office or other outpatient visit for the E/M of an established patient that requires two of these three key components: a detailed history, a detailed examination and medical decision-making of moderate complexity. Physicians typically spend 25 minutes with the patient).

The table, which CMS includes in the E/M Documentation Guidelines, means that the risk associated with a patient who requires antibiotic treatment may be at the moderate level or near it.

Key: Medical necessity must guide the elements that the pediatrician performs and documents. For instance, the following note supports 99214.

• CC: Fever and vomiting

• HPI: Congestion and wet cough for four days, Temp to 103 for two days, Vomiting 2x today; Irritable with poor feeding, sleeping

• PFSx: Hx otitis x 3 in past 6 mos; Fhs others ill resp illness

• Shx: Parents smoke

• PE: temp 102.5, RR 24, Wt 22lbs

• Fussy but responsive; skin flushed, turgor good;

TM's erythematous, bulging; pharynx mod erythema; neck supple; chest clear to auscultation; heart reg rhythm without murmur; abdomen soft, without masses,tenderness; neuro irritable but responsive

• Impression: Otitis media, recurrent; vomiting; fever

• Rx: Amoxicillin, Tylenol, clear fluids with diet advanced as tolerated; discussed in detail including parents' concerns with recurrent ear infections

• F/U ear recheck in 2 to 3 weeks.

The chart includes these 99214 qualifying elements:

• five history of present illness (HPI)

• three past, family and social history (PFSH)

• eight review of systems (ROS).

With an additional two ROS and one PFSH, the visit could have qualified as 99215, which requires four elements of HPI, 10 ROS elements and two of three PFSH elements. Alternatively, if the pediatrician had spent more than 20 minutes of a 40-minute visit counseling the parents on possible surgery and hearing loss concerns, he may have coded 99215 based on time.

For the diagnoses, you would code acute otitis media (382.00), vomiting (such as 787.03, Vomiting alone) and fever (780.6). OM with systemic symptoms noted supports the medical necessity of 99214 for this visit.