Pediatric Coding Alert

Question: A pediatrician's note indicates, "Patient complains of sore throat past two days. Temp 104. No vomiting. Cough. H1N1 exposure at school."

Florida Subscriber

Answer: Documentation, such as "Exposure at school" or "No exposure" counts as past medical family social history (PMFSH). "No exposure" goes to the patient's past experiences with illnesses, which is past medical history. "Exposure at school" gives information about the patient's current activities, which is part of social history.

You need only one PMFSH item for pertinent PMFSH. Without pertinent PMFSH, the highest history that a visit can qualify for is an expanded problem focused history. "Without PMFSH, you can't have a detailed history,"supporting 99214 (Office or other outpatient visit for the evaluation and management of an established patient ...) in an established patient, noted Donelle Holle, RN, in "You Can Survive a Chart Audit" at The Coding Institute's December 2010 National Pediatric Coding and Reimbursement Conference in Orlando, Fla. "The good thing -- if there is a good thing -- about H1N1 is that it got providers thinking about PMFSH," she said.

Your history note as written supports a detailed history (99214). "Patient complains of 'really painful' (history of present illness [HPI]: quality) sore throat (CC) past two days (HPI: duration). Ht 42, Wt 38, Temp 104 (Review of systems [ROS]: constitutional for three or more vital signs). No vomiting (HPI: associated signs and symptoms or ROS). Cough (ROS -- since you only need one associated sign and symptom to give credit for this HPI element). Tried gargling with salt water (HPI: modifying factor), which helped a little. H1N1 exposure at school (social history)." You have four HPI elements, which gives you an extended HPI. The vital signs and cough give you two ROS elements, which counts as an extended ROS. Extended HPI + extended ROS + pertinent PMFSH = Detailed history.

--Information and/or answers for You Be the Coder and Reader Questions provided and/or reviewed by Norman "Chip" Harbaugh, MD, pediatrician practicing in Atlanta; Donelle Holle, RN, consultant with www.Pedscoding.com in Indiana; Scott Manaker, MD, PhD, American College of Chest Physicians Relative Value Update Committee (RUC) representative; and Richard Tuck, MD, FAAP, pediatrician at PrimeCare of Southeastern Ohio in Zanesville.