Pediatric Coding Alert

Question: During a newborn preventive medicine service, the pediatrician addresses the child's goopy eye.

Actual documentation reads exactly as follows:

Date: 5/18/09 Age: 13 days R eye goopy

Ht. Wt. HCM NB F/UP Not every day

6 lb 4 oz Warm cloth to wipe it

Sim Adv: eating 2 oz e 3 h

BM & urine OK sees & hears

PE: Alert vigorous AF/PF flat +RR

HEENT φ re wet R eye chest cor abd φ umb attached hips stable φ O/B/G all else well

I: doing well mild dacryocystitis

P: wt -- 10d Eythro Ophth Oint Safety US hips in June R: 10d & 7wks+ 2 mo

Should the pediatrician report an E/M-25 for the eye care?

New Jersey Subscriber

Answer: "Yes, I could have added 99212-25 (Office or other outpatient visit for the evaluation and management of an established patient which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination, and straightforward medical decision making; Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for the ‘goopy eye' which I treated, but I didn't," says Charles Scott, MD, FAAP, a pediatrician at Medford Pediatric and Adolescent Medicine in New Jersey. Despite the oversight, the above documentation does supports 99212-25 with 375.30 (Dacryocystitis unspecified) in addition to 99391 (Periodic comprehensive preventive medicine service reevaluation and management of an individual ...; infant [age younger than 1year) linked to V20.32 (Health supervision for newborn 8 to 28 days old).

Let's break down the notes that are significant and separately identifiable from the preventive medicine service. Although you have moderate risk prescription drug management (antibiotic: Eythromyicin Ophthalmological Ointment), the two straightforward elements (problem: 1 point for a minor problem, and data: 1 point for obtaining history from someone other than the patient) pull the medical decision making down to straightforward.

You could count HEENT φ under either ROS or exam. Whichever way you use the component, you count HEENT φ under results in that area being expanded problem focused and the other area as problem focused.

Straightforward medical decision making with an expanded problem focused history/exam and a problem focused history/exam makes the MDM the driving factor in meeting an established patient's 2 of 3 key components' requirement for 99212.

If you count HEENT under history, you get expanded problem focused history. You have four elements of history of present illness (HPI) (extensive): location (right), quality (goopy), timing (not every day), modifying factors (warm cloth to wipe it). The head and ears, nose, and throat (1) count as one system for a problem focused ROS. No personal, family, and social history (PFSH) pulls the type down to an expanded problem focused history.

Counting HEENT φ under ROS leaves you with wet eye for the exam. One organ system supports a problem focused exam.

If you instead count the HEENT φ under the exam in addition to the wet eye, you get three body areas/organ systems examined: head (body area), ears, nose, and throat (organ system), eye (organ system). Up to seven systems is considered an expanded problem focused exam. You then, however, have no ROS, making the history problem focused: 4 HPI + 0 ROS + 0 PFSH = problem focused history. Straightforward medical decision making still causes this combination (problem focused history, expanded problem focused exam) to support 99212.

Abbreviations: AF/PF: Anterior/posterior fonatanel flat; -O/B/G: Hips stable with negative Ortalani, Barlow, Galleazzi signs; RR: Red reflex; Sim: Similac.