Pediatric Coding Alert

Question: When I am levelling an office/outpatient evaluation and management (E/M) service, can I pull information from elsewhere in a patient’s record even if the provider does not specifically link that information to the medical decision making (MDM) for the problem at hand?

For example, a pediatrician sees a patient following surgery and documents “the patient is doing well. I will follow up in three months.” There is no mention of any prescription medication or any kind of management of the patient’s condition for this encounter. However, the patient is a documented type 1 diabetic. Can I consider this information when choosing the MDM level for the encounter? Would this be a 99212 based on the plan the pediatrician has documented, or could I justify a 99213 because of the patient’s other health problems?

AAPC Forum Participant

Answer: In situations like this, you, as a coder, cannot infer from the patient’s record that a patient’s past or present medical conditions will in any way affect the course of action your pediatrician has determined for the specific condition being treated. Unless your pediatrician specifically indicates in the note that a given condition or conditions are present and are, or will, affect or influence treatment for the condition the patient is presenting for, you cannot factor any concurrent condition into the MDM for a given encounter.

Without knowing the full details of the encounter, the MDM level in this situation probably does not rise above straightforward. As you say, there is no prescription management or any treatment of any kind for that matter. Additionally, there is no indication the patient’s diabetes is being evaluated or treated at the encounter, so you can’t count it as among the number and complexity of problems addressed. Lastly, you do not indicate whether there is any data to be analyzed. So, if that is the case, whether or not you regard the patient’s surgery as being an acute, uncomplicated illness or injury, you cannot make the case for this office/ outpatient E/M to rise above 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making …).