Pediatric Coding Alert

Question: I'm auditing a note that reads: "12-yr-old with new prob. Pharyngitis." There's no HPI, but the pediatrician does an "Exam on TM" that he documented with some detail. He also documents a lung exam with some detail. He writes a prescription for Keflex. Using the 1995 guidelines, do two detailed body areas exams, a new problem and a prescription written qualify for a level-four established patient visit?

Utah Subscriber

Answer: Yes, using the medical decision-making (MDM) standard audit sheet that CMS included in the 1995 guidelines, the items you list support 99214 (Office or other outpatient visit for the E/M of a patient, which requires at least two of these three key components: a detailed history, detailed exam, and medical decision-making of moderate complexity).

A new problem and prescription writing qualify as moderate-complexity MDM, which, combined with a detailed examination (an extended examination of the affected body area[s] or organ system[s] and any other symptomatic or related body areas[s] or organ system[s]), meets two of the three components for a level-four established patient visit.

Here's how the above would score in MDM, which requires two out of three for a given MDM level. Your case includes these levels:

• number of diagnoses or treatment options (new problem -- 3 points) = multiple

• highest risk (prescription) = moderate

• amount and complexity of data (0) = minimal.

This type of documented MDM combined with a detailed history and/or a detailed exam documentation supports 99214. The pediatrician examined two body areas or systems -- ears, nose, mouth and throat (tympanic membrane, TM) and respiratory (lungs) -- in detail, which supports a detailed examination (99214).

The only difference between physical exams for 99213 and 99214 is that one is "limited" and the other is "extended," according to the CMS guidelines. Your physician can review two to seven areas or systems for either code. What's different is how much detail the doctor goes into about each area or system. Therefore, you have two of the three components.

Because the documentation contains no elements of review of systems (ROS), your third component supports only a problem-focused history (99212).

The 1995 guidelines consider brief history of present illness (one to three elements) without ROS as problem-focused history. You have one HPI element, pharyngitis. An expanded problem-focused history (99213) requires one to three elements of HPI and positive responses and pertinent negatives for the system related to the problem.