Pediatric Coding Alert

The AAP has proposed guidelines that are relevant to pediatrics. These guidelines are now under review by an E/M workgroup at the AMA, says Linda Walsh, senior health policy analyst with the AAP division of healthcare finance and practice. Although not officially sanctioned by CMS, these guidelines will help pediatricians who now have little to go on but the guidelines for adults. After several more meetings, the last one in June, the workgroup will make recommendations to the CPT editorial panel.
 
An E/M service consists of three basic components: history, examination and medical decision-making. New patient E/M codes (99201-99205) require that all three components be met to justify a certain level; established patient codes (99212-99215) require only two of three.

Do not base a level of service only on the diagnosis codes. The same diagnosis could mean a different level based on the situation. For example, an otitis media diagnosis such as 382.00 (Acute suppurative otitis media without spontaneous rupture of ear drum) not requiring antibiotics could be a 99212, while a history of recurrent 382.00 possibly requiring surgery could be a 99214. Or, a patient might have a nonurgent diagnosis such as fatigue (780.79) and the medical decision-making involved may be complex enough to support a high-level code.

The history includes the chief complaint (CC), the history of the present illness (HPI), the review of systems (ROS), and the past, family and social history (PFSH), based on the level of service. For CPT 99201 and 99212, a problem-focused history must be documented, including CC and brief HPI. For 99202 and 99213, an expanded problem-focused history must be documented, including CC, brief HPI, and problem-pertinent ROS. For 99203 and 99214, a detailed history must be documented, including CC, extended HPI, a problem-pertinent ROS with additional systems, and a pertinent PFSH. For 99204, 99205, and 99215, a comprehensive history must be documented, including CC, extended HPI, complete ROS, and complete PFSH.
 
Code choice is technically based on the number of elements from each category. But looking at the CC and, sometimes, the diagnosis can give a better "feel" for a certain level.

Chief Complaint
 
Although the CC is essential to every E/M service, it does not necessarily affect the level of service. The CC may be the same as the final diagnosis.
 
The CC is directly related to the presenting problem, which contributes to the level of service chosen. The presenting problem is categorized as minimal (99211), self-limited or minor (99201, 99212), low severity (99202, 99213), moderate severity (99202, 99203, 99213, 99214), or high severity (99204, 99205, 99214, 99215).
 
For a neonate or infant, examples of a CC include normal newborn exam, cough, crying/irritability, feeding problems, rash, fever or difficulty breathing. There is often no direct relationship between the CC and the diagnosis that is established. For a child or adolescent, examples of the CC include abdominal pain, behavior or discipline problems, ear pain, trouble at school, wheezing, cough or diarrhea.

History of Present Illness
 
In neonates or infants, an example of a brief HPI would be feeding problems (779.3, Feeding problems in newborn; or 783.3, Feeding difficulties and mismanage-ment), diaper rash (691.0, Diaper or napkin rash), or a well-baby visit (V20.2, Routine infant or child health check). An extended HPI could be for a fever (780.6), vomiting (787.03) or diarrhea (787.91).
 
In children and adolescents, examples of a brief HPI include ankle sprain (845.00, Sprains and strains of ankle and foot; ankle; unspecified site), earache (388.70, Otalgia, unspecified), sore throat (462, Acute pharyngitis) and warts (078.10, Viral warts, unspecified). An extended HPI could be for recurrent or chronic abdominal pain (789.0x, Abdominal pain), ADHD (314.01, Attention deficit disorder; with hyperactivity), a chronic cough (786.2, Cough), growth problems (783.4x, Lack of expected normal physiological development in childhood), recurrent headaches (784.0, Headache), or chronic fatigue (780.79, Other malaise and fatigue).
 
The HPI for the neonate should include prenatal history and perinatal history.
 
The AAP guidelines state that the review of systems is not required for a newborn.

Family and Social History
 
For the neonate, FSH must include previous fetal or neonatal problems. For the infant, include pertinent elements of the history of other neonates and children in the family. For the child or adolescent, include the neonatal FH, and histories of various illnesses in the family. For the SH, include guardianship issues, family and marital issues, domestic abuse, substance abuse, insurance coverage/limits, family stress, adequacy of home environment, environment (such as lead paint), daycare/latch-key issues, and attitude toward discipline.

The four levels of examination are problem-focused (99201, 99212), expanded problem-focused (99202, 99213), detailed (99203, 99214), and comprehensive (99204, 99205, 99215). CPT states that "age and risk factors" contribute to determining the extent of a comprehensive exam. For a given problem or age, the pediatrician doesn't necessarily need to count every system, so CPT gives pediatricians leeway on the examination.

The medical decision-making is often the most crucial element in selecting a level of service. Pediatricians have patients who can't communicate their condition clearly, so their medical decision-making must be broad.
 
Physicians must choose between straightforward (99201, 99202, 99212), low complexity (99203, 99213), moderate complexity (99204, 99214), and high complexity (99205, 99215) medical decision-making. The type of decision-making is based on the diagnosis and/or risk of complications, the procedure or test and/or data reviewed, and management options.

Neonate/Infant
 
Diagnosis and/or risk of complications: Examples of low medical decision-making in this category include, for a neonate: a term vaginal delivery (V30.00, Single liveborn; born in hospital; delivered without mention of cesarean delivery), jaundice (774.6, Unspecified fetal and neonatal jaundice), erythema toxicum (778.8, Other specified conditions involving the integument of fetus and newborn) or conjunctivitis (771.6, Neonatal conjunctivitis and dacryocystitis); for an infant: feeding problems, minor umbilical drainage (762.6, Other and unspecified conditions of umbilical cord), diaper rash, or an upper respiratory infection (URI) (465.9, Acute upper respiratory infections of multiple or unspecified sites; unspecified site).
 
Examples of moderate medical decision-making include, for a neonate: 35- to 37-week gestation (765.1, Disorders relating to short gestation and unspecified low birthweight; other preterm infants), maternal diabetes (775.0, Syndrome of "infant of a diabetic mother"), or transient tachypnea (770.6); for an infant: acute gastroenteritis (558.9, Other and unspecified noninfectious gastroenteritis and colitis), and acute croup (464.4, Croup).
 
Examples of high medical decision-making include, for a neonate: less than 35 weeks gestation (765.1 or 765.0, Extreme immaturity), and respiratory distress syndrome or hyaline membrane disease (769); for an infant: RSV bronchiolitis (466.11, Acute bronchiolitis due to respiratory syncytial virus [RSV]) or acute gastroenteritis with dehydration (558.9 and 276.5, Volume depletion).
 
Procedure/test and or data reviewed: The pediatrician does not necessarily perform these tests, but orders them and reviews the data. Examples of low medical decision-making in this category include noninvasive tests such as bilirubin or urinalysis, screening tests such as phenylketonuria (PKU), T-4, sickle cell, a hearing screen and arterial puncture. Examples of moderate decision-making include a spinal tap, a computed tomography (CT) scan or magnetic resonance imaging (MRI), a bladder tap, an arterial line, circumcision, echocardiography, intracranial ultrasound, and umbilical vein or catheter. Examples of high decision-making include thoracentesis or an intraventricular tap.
 
Management options: Examples of low medical decision-making in this category include vitamin K, phototherapy, gavage feedings, oral antibiotic therapy, fever treatment, parental education, and intravenous hydration. Examples of moderate medical decision-making include parenteral antibiotic therapy, hospital admission, specialist referral, and total parenteral nutrition (TPN). Examples of high medical decision-making include transport to another facility, ventilator therapy, treatment of cardiogenic shock, major surgery, "do not resuscitate" (DNR) decision, and exchange transfusion.

Child/Adolescent
 
Diagnosis and/or risk of complications: Examples of low medical decision-making for a child or adolescent in this category include acute gastroenteritis, nosebleed (784.7, Epistaxis), otitis media (381.xx, Nonsuppurative otitis media and Eustachian tube disorders; or 382.xx, Suppurative and unspecified otitis media), pharyngitis (462, Acute pharyngitis), tonsillitis (463, Acute tonsillitis) and URI. Examples of moderate medical decision-making include acute croup (464.4), acute gastroenteritis with moderate dehydration (558.9 and 276.5), asthma (493.0x, Extrinsic asthma), chronic eczema (692.9, Contact dermatitis and other eczema; unspecified cause), pneumonia (486, Pneumonia, organism unspecified), and pyelonephritis (590.10, Acute pyelonephritis; without lesion of renal medullary necrosis). Examples of high medical decision-making include acute epiglottitis (464.30, Acute epiglottitis; without mention of obstruction), meningitis (320.x, Bacterial meningitis) and multiple somatic complaints.
 
Procedure/test and/or data reviewed: Examples of low medical decision-making for a child or adolescent in this category include cultures (throat, urine, stool, eye), tympanometry, rapid strep screen, mononucleosis test, CBC and blood chemistries. Examples of moderate medical decision-making include imaging studies with contrast, CT/MRI, foreign-body removal, allergy testing, spinal tap, and pelvic examination. Examples of high medical decision-making include a thoracotomy tube, bone-marrow aspiration, and biopsy.
 
Management options: Examples of low medical decision-making in this category include oral antibiotic therapy, topical therapy, over-the-counter therapy, symptomatic management, fever treatment, parental education, oral hydration, and IV fluid therapy. Examples of moderate medical decision-making include hospital admission, specialist referral, parenteral antibiotic therapy, minor surgery, nebulized aerosol treatment, outpatient acute care facility treatment, and TPN. Examples of high medical decision-making in this category include parenteral antibiotic therapy with blood-level monitoring, cardio-respiratory support, hospital ICU care, transfer of care to an intensivist, major surgery, ventilator therapy, and DNR decision.