Pediatric Coding Alert
Pull Out This Month's 'Destroy Downcoding' Lesson
Staff can test their 99213-versus-99214 skills You can educate pediatricians, medical assistants (MAs), secretaries and coders on 99214's history and exam components without burdening them with too much coding homework. Don't Overlook History, Exam Elements Your office could be sacrificing $30 for visits that really are 99214s (established patient office visit). Pediatricians often perform history and examination elements but fail to record that information. Pediatricians may not realize that jotting down these details could justify a 99214 instead of the safety of CPT 99213 . Document This Doctor's Work Have the pediatricians who choose the levels, the MAs who write the CCs, the coders who perform chart audits, etc., see what information is missing from the following documentation: The physician asks the parent if the child is pulling at his ears. He inquires about: The examination includes looking at the ears; checking the head, nose and throat; palpitating the lymph nodes; listening to the chest; and probing the belly. Capture Work With History Breakdown If the pediatrician recorded these details, she should have turned the above chart note from 99213 into 99214 (fill in the blanks): Action: Discuss everyone's answers. Some questions you can pose: What history questions did the pediatrician ask but fail to record? What exam elements did the pediatrician check but not include in the documentation? Did the template help staff remember all the possibilities? Discuss These Performed, But Overlooked Items Using a template would have helped the MA and pediatrician remember to record: Documentation now meets 99214's requirements.
Opt for a monthly training session using this quick quiz with talking points instead.
Example: A 2-year-old child presents with a chief complaint of cough, cold and fever that the MA records. The pediatrician comes in and asks:
Documentation reads: Child here today for fever and congestion of two days, worse at night. Pulling at ears and eating poorly. Hearing appears fine. Tympanic membranes bulging and red. Ear purulent. Chest clear. Wrote prescription. Recommended FU in 10-14 days, sooner if symptoms not improving.
Codes selected: 99213, 382.00 (Acute purulent OM).
Hint: Remember to capture all the pediatrician's work with this template.
S CC: _____________________________________
HPI: ____________________________________
ROS: ____________________________________
PFSH: ___________________________________
O _________________________________________
S CC: fever, congestion
HPI: severity (screaming), fussiness, associated symptoms: cough, cold, throat hurting, drainage, fever (adding two of these details changes the HPI from two to four elements and moves HPI from brief to extended)
ROS: constitutional (appetite), respiratory (cough), gastrointestinal (stomach) (recording the detail of just two of these area equals an extended ROS, rather than a pertinent ROS)
PFSH: past history of illness, family (members sick), social (school) (documenting any one of these elements makes the PFSH pertinent instead of NA)
O Head "Normal"
Gastrointestinal "Normal"
Lymphatic "Normal"
(Checking that three additional systems are "normal" moves the exam from the 99213-required 2-4 systems to 99214's requirement of 5-7 systems.)
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