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Pediatric Coding Alert

Reader Questions:

Count Extra Minutes Before Increasing E/M for Counseling

Published on Thu Jun 03, 2010

Question: We've found increased BMI during well visits for several children lately. The pediatrician spends additional time on discussion, referring the child to a dietitian, and scheduling lab tests. We're having trouble deciphering the amount of documentation needed and when we're justified in coding a higher level E/M visit. What should we keep in mind?Oklahoma SubscriberAnswer: Base your codes for this type of significant, distinct problem on the amount of time spent on counseling and coordinating care. If your pediatricians do their own coding, they know how much extra time and effort went into the counseling so should code accordingly. If your providers don't do their own coding, train them to make a note in the chart regarding how much extra time they spent with the patient addressing the problem.Once you know the timeframe, you can choose the appropriate code. You'll probably report 99212 (Office or other outpatient visit for [...]
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