Pediatric Coding Alert

Question: The 1997 audit guidelines state that I can reach an extended history by updating the status of at least three chronic or inactive conditions. Does this information have to be in the history of present illness (HPI) section of the note, or may I pull the information from the assessment section of the note?


Colorado Subscriber

Answer: You can count the information in the assessment as a condition status update. The pediatrician may organize the notes in any manner he finds practical. For instance: He may update the illness(es) in the assessment section rather than in the HPI at the front of the visit, although for audit purposes it may be helpful to reference them in the HPI section, too.

Using the 1997 guidelines may help you report higher-level services for patients who have chronic conditions, such as attention deficit disorder (ADD) and asthma. Unlike the 1995 version, the 1997 history elements don't require the four elements of HPI for an extended level of HPI because you can use the status of three or more chronic conditions. Therefore, the 1997 guidelines may allow you to report a higher-level E/M code for encounters that involve periodic prescription renewals without the pediatrician having to go into as much detail.

Example: A patient who has controlled type I diabetes (250.01, Diabetes mellitus without mention of complication; type I [juvenile type], not stated as uncontrolled), controlled asthma (493.01, Extrinsic asthma; with status asthmaticus) and attention deficit disorder (314.00, Attention deficit disorder; without mention of hyperactivity) presents for a follow-up of his diabetes and asthma.

After an appropriate exam, the pediatrician renews the patient's prescription and notes:

• diabetes--active, stable
• asthma--active, stable
• ADD--active, stable.

Because the physician indicates the status of at least three chronic or inactive conditions, using the 1997 guidelines you may report an extended HPI. When combined with an appropriate review of systems and past, family, and social history, the extended HPI may result in a detailed history.

If the pediatrician performs either a detailed examination or moderate-complexity medical decision-making, you may report the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...). Remember: Medical necessity should ultimately drive the visit's history and examination.