Pediatric Coding Alert

Question: Documentation for an established patient visit includes these items:

Chief complaint ��" ear pain and cold

Physical exam ��" head, ear-nose-throat, chest, abdominal, skin, and neuro

Assessment ��" otitis media (OM) and upper respiratory infection (URI)

Plan ��" amoxicillin prescribed.

Because the physician did not document any history, for auditing purposes, I'm focusing on the exam and medical decision making (MDM). Should I consider the physical exam comprehensive and the decision making moderate or low?

Washington Subscriber

Answer: The physician documents examining six body areas and organ systems. Using 1995 E/M guidelines, up to seven systems counts as an expanded problem focused exam. For the exam to qualify as detailed, the physician would have to

perform and document an extended medically necessary exam of the affected area(s) and other symptomatic or related organ systems. A comprehensive exam requires documentation of eight or more systems.

As for MDM, the ear pain and cold count as two self-limited or minor problems, and the prescription drug management counts as moderate risk. You have zero data reviewed or ordered. Because MDM requires two of three, you have MDM of low

complexity.Established patient office visits require two of the three key components with the presenting problems determining the extent of the medically necessary history and exam. An expanded problem focused examination and MDM of low

complexity support 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused

examination; medical decision making of low complexity ... Usually, the presenting problem[s] are of low to moderate severity ...).