Pediatric Coding Alert

The Evaluation and Management (E/M) services codes covering the sick visits that are the staples of a pediatric practice do not allow time to be used as a key factor in determining which level of service to bill. This can be very frustrating to pediatricians, who may have a relatively simple case that requires 45 minutes of their time, usually because the child needs careful handling. (Unlike adults, children cant be expected to sit still for everything.) The three key factors in determining the level of service are the history, examination, and complexity of medical decision-making.

After the key components of history, examination, and medical decision-making, there are three other components that can be considered contributory factors. These are counseling, coordination of care, and the nature of the presenting problem. The seventh component, which cant be used at all, is time.

Note: There is an exception for counseling/coordination of care, which is explained in a later section of this article.

1. Time has been considered as a factor. It came up for debate when revising the Evaluation and Management Service codes for 1990-1991. But CPT must apply across all specialties, and not all physicians liked the idea of time. A procedure may take a short amount of time but be extremely complicated; the patients life may depend upon it. Surgeons may feel that time is an unfair gauge to use. There is physically demanding work, and there is mentally demanding work. Many physicians felt that the demands of the work, and not the actual time spent, would be a better way to measure what they do. These physicians would like medical decision-making to be the main factor. If the CPT Codes were to say that every 15 minutes had to be paid for by someone, then it would have to answer these physicians claims that not every 15 minutes are the same. And, in fact, many pediatricians agree with that.

2. Using time as a factor would affect the physician-patient relationship. Another problem with using time as a key factor is the stopwatch concept. Some physicians feel this would be intrusive. Your patients and their parents would surely agree.

Remember, these are the 90s. If you base pay on time, in effect, the American Medical Association says, youre rewarding inefficiency. Why should you penalize the physicians who can see more patients in a day because theyre efficient? Furthermore, once you start down this road, you may not like where you end up. Lets say youre being asked by health plans to get more patients through faster, and to see more patients. If you are billing strictly on time, the money you get is basically a salary. If suddenly you find you have more patients or sicker patients, youre not going to get paid more.

So, when you have that patient for whom it takes half an hour to do a throat culture, take heart. You may be only getting paid for a 99212, but your expertise is being rewarded in other waysother higher codes, yes, and also the fact that you are more than a metered service.

3. The counseling exception. There is one situationcommon in pediatricsin which you can use time not only as a key factor, but as the key factor, in determining the level of service. These are cases where counseling and/or coordination of care take up more than 50 percent of the encounter time. So if a baby comes in with diaper rash (usually 99201-02 for a new patient or 99211-12 for an established patient) that takes up five minutes of your time but you end up talking to the mother for 25 minutes about sleeping problems, you should upcode to 99204 or 99214. However, you must be careful to document the time you spent, and the nature of the counseling.