Pediatric Coding Alert

Question: How should I code this follow-up visit? A patient returned to our pediatrician after injuring her left shoulder. Our pediatrician reviewed the patient’s magnetic resonance imaging (MRI) scan that had already been ordered, ordered physical therapy, and prescribed a refill on an anti-inflammatory. Can I bill this as a 99214 based on a unique test (the MRI) and prescription drug management?

AAPC Forum Participant

Answer: The medical decision making (MDM) level to this encounter probably doesn’t rise to a level four office/outpatient evaluation and management (E/M) visit.

Here’s why.

Prescription drug management in this situation may rise to the moderate level of risk even though it’s a refill if the pediatrician has changed the dosage of the medication. However, the injury itself probably only rises to the level of a single acute, uncomplicated injury, which would give you a low level for the number of problems addressed at this encounter.

As for the MRI, if it was ordered at the patient’s first visit, the review would be counted on that date of service, not on this encounter. If you are counting it on this date of service, then it only reflects a limited amount and/or complexity of data, as it only meets the requirements of Category 1 (review of the result(s) of each unique test). As you do not indicate whether there was an independent historian interpreting the test, or note any discussion of test interpretation with an external physician or other qualified healthcare professional (QHP), then this element cannot rise to the moderate level.

At best, this encounter probably only justifies billing 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making….).