Pediatric Coding Alert

The point system is used in scoring medical decision-making, one of the three key factors (along with history and examination) which go into selecting an evaluation and management (E/M) service level. The medical decision-making system is a creation of the American Medical Association (AMA) for their CPT system, in cooperation with Medicare. Pediatric coders who are not used to dealing with Medicare may not be familiar with scoring medical decision-making. However, as compliance broadens from a Medicare-only perspective to a general payer perspective, youre going to need solid meaning quantitative support for your level of service. Pediatricians are all too aware of the fact that private payers are starting to downcode claims, reducing codes 99214 and CPT 99215 to 99213.

The payer believes you are overcoding, so they fix the problem for you, says Thomas Kent, CPC, CMM, president of Kent Medical Management in Dunkirk, Md. Overcoding means your documentation does not support the level of service billed. Some payers are now requiring documentation before paying any level four or level five claim. Having the documentation of medical decision-making will help support you in fighting for a 99214 or 99215. The problem, says Kent, is that in general, physician documentation is so poor that doctors make an easy target.

You need to write down everything that goes into your medical decision-making. But, you also can score medical decision-making with points, and thats exactly what payers want you to do.

There are three components which determine the level of medical decision-making: the number of choices, the complexity of data, and the level of risk.

1. Number of choices. The number of diagnosis and management options is charted on a scale of one to four points. Each established problem (established means that the pediatrician has seen this problem in this patient before) which is stable or improving is worth one point. Each established problem which is worsening or not improving is worth two points. The established problems are cumulative, so it is important to list each problem that the provider considers during the office visit. If the patient presents with a problem new to the provider and no further workup is necessary at this session i.e., diagnosis is complete and treatment is initiated this is worth three points. If the new problem will require further diagnostic testing, this is worth four points.

2. Complexity of data. The amount and complexity of data reviewed is figured on a scale of one to four. Each category of diagnostic testing ordered or reviewed is worth one point. The categories are laboratory (80000 series), radiology (70000 series) and medicine (90000 series). Ordering a complete blood count (CBC) and a chest x-ray is worth two points. Ordering a urinalysis, CBC and chest x-ray is also worth two points because the first two items are both in the laboratory category. Deciding to obtain records from another provider is wortth one point. Personally visualizing an x-ray film or other diagnostic image is worth two points. Obtaining patient history from someone other than the patient is worth two points. All of these items will work if they are mentioned in the medical record for that date of service.

3. Level of risk. In pediatrics, determining the risk is easy, says Kent. If you look at treatment options, a cold compress is minimal risk, over-the-counter medication is low risk, prescription medication is moderate risk, and medication requiring close monitoring is high risk.

Here is an example of a pediatric scenario and how the encounter would be scored according to medical decision-making:

A two-year-old male child is seen for a follow-up of otitis media. The ears are clear but the child has developed thrush (112.0).

Scoring:

Number of choices: Otitis media, resolved one point; thrush, new problem with no workup three points; Total four points (high level of diagnostic problems).
Complexity of data: History obtained from the mother two points (low level of data complexity).
Level of risk: Prescribe an antifungal to treat the thrush (moderate level of risk) the risk component does not utilize points.
To arrive at a final score, you choose the highest two which meet or exceed the level. In this case, the total medical decision-making would be moderate.

Editors note: Currently, a new system which utilizes different scoring is under review. We will bring you details as it gets closer to reality. In the meantime, however, the HCFA 1995 guidelines for E/M documentation would apply.