Pediatric Coding Alert

You can't use just history and examination to boost an established office visit from a level two to a level three, or a level three to a level four.

Medical necessity should serve as the overarching criteria that steers the key components of history and exam that the pediatrician performs. You also need documentation of two of the listed three key components of history, examination and medical decision-making (or when the pediatrician spends the majority of the encounter's face-to-face time on counseling and/or coordination of care, she can use time as the controlling factor in selecting the E/M service level):