Pediatric Coding Alert

Question: Which CPT code should I use for this case: An established 7-year-old patient presents for an office visit with complaint of headaches off and on for two to three months. The headaches are associated with some nausea. No complaint of vision difficulty. The pediatrician takes an appropriate history and performs a comprehensive exam. She finds no physical findings for the headache and orders appropriate testing.

California Subscriber

Answer: With proper documentation, this encounter could support a level-five established patient office visit. You already have one component -- a comprehensive examination -- of the two components required for 99215 (Office or other outpatient visit for the evaluation and management of an established patient ...).
 
Several factors contribute to meeting a second key component of 99215 -- high-complexity medical decision-making (MDM):

 • The risk for morbidity is high because the diagnostic differential involves ruling out a possible brain tumor.
 • You have ordered lab tests, which raises the level of risk.

Based on the Marshfield Clinic's audit worksheet (available from the Medical Group Management Association at 877-275-6462 or by visiting www.mgma.com/ecom/default.aspx), the above factors indicate MDM of high complexity. Here's how:

 • You would receive 4 points (extensive) under the Number of Diagnoses or Treatment Options for "New problem (to examiner): additional workup planned."

 • For ordering appropriate testing, you receive 1 to 3 points in the Amount and/or Complexity of Data Reviewed category. Give 1 point each for "Review and/or order of clinical lab tests," "Review and/or order tests in CPT radiology section (except echocardiography and cardiac cath)," and "Review and/or order tests in CPT medicine section (EKG, EEG, echocardiography, cardiac cath, etc.)." Having 1 to 3 points equates to minimal-moderate.

 • In the Risk of Complications and/or Morbidity or Mortality category, the presenting problems qualify as highest risk, which includes "Acute or chronic illnesses or injuries that may pose a threat to life or bodily
function, e.g., multiple trauma acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure." In addition, management options may include major surgery (highest risk).
 
Result: A combination of extensive diagnoses or treatment options and highest risk suggests MDM of high-complexity.