Pediatric Coding Alert

Question: Since prescription management involves moderate risk on the CMS standard documentation worksheet and the pediatrician in the following chart note (which appears exactly as written without grammatical correction and spelling out abbreviations) prescribes medication, I am planning on submitting the encounter with 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; medical decision making of moderate complexity …Usually the presenting problem[s] are of moderate to high severity …). Is my visitl eveling correct for a note that reads:

8-year-old male; wt 114, temp 99.4, R 20; rash on face, arms, legs �" mostly all over �" X 5 days/ Nurse signature cc? poison oak -- by eye x 4-5 days, + on hands, trunk, pvt area

Rx lamisil -- “anti-itch cream --

Plays in the woods.

PE �" alert, uncomfortable

Skin 1 x ¾ cm patch R nasal bridge

1.5 x 1.5 cm patch R lower wrist area

1 cm patch scrotum

Impression -- contact dermatitis; probable poison ivy

Disp

Discussed in detail -- + avoidance

Prednisone 10 mg/tab

(tab qid x 3 days ?

Tid x 3 days ?

Bid x 3 days ?

Qam x 3 days ? DC)

Benadryl prn.

Re prn./Doctor Signature.

Ohio Subscriber

Answer: Your documentation supports only a level two established-patient visit (99212, … problem focused history; problem focused examination, and straightforward medical decision making ... Usually the presenting problem[s] are self limited or minor …). Moderate risk does not automatically mean moderate medical decision making and does not necessarily equal 99214.

When you combine moderate risk with MDM’s other factors--Number of Diagnoses or Treatment Options (selflimited/ minor = 1 point), and Amount and/or Complexity of Data Reviewed (none = 0 points)--you get straightforward MDM. CPTAppendix A, which physicians can use as a measure of a presenting problem’s level, lists an example of 99212 (self-limited or minor problem) as an “Office visit for a 65-year-old, established patient, with eruptions on both arms from poison oak exposure.”

While medical decision making should steer the visit, this visit would still not qualify for 99214 based on history and exam alone (two of three for 99212-99215). Using the 1995 E/M documentation guidelines, the exam, which is focused on the skin, is really a problem focused exam even though it technically includes two body areas/systems: constitutional (vitals, alert, uncomfortable) and skin. The documentation supports expanded problem focused history (requires three of three):

• Brief history of present illness (one to three elements: location - face, etc.; quality - all over; duration - x 5 days)

• Problem pertinent review of systems (one system: integumentary)

• Comprehensive past medical, family, social history (PFSH) (two areas: personal -- Rx lamisil and anti-itch cream, and social -- plays in woods).

The straightforward MDM and problem focused exam make the visit 99212.