Pediatric Coding Alert

Question: Which code should we report for evaluation of an ear ache, sore throat, runny nose, and fever? We can’t decide whether it qualifies for 99213 or 99214.

Answer: This question supports a common myth--that each type of diagnosis has a standard E/M code associated with it. However, your E/M code should be based upon what the documentation supports, which can differ greatly even with the same diagnosis. An ear ache, runny nose, and fever patient may have other chronic conditions, taking the complexity quite high--or he may simply have a common cold, which could be lower.

Therefore, you’ll have to review the documentation to determine which level of history, exam and medical decision-making appear in the chart. Once you determine those, you can select the appropriate E/M code.

Going forward, review your coding choices to confirm that clinicians aren’t choosing the same level of service for every claim relating to the same diagnosis. For example, if the pediatrician primarily sees patients with cystic fibrosis and charges 99215 for every visit because cystic fibrosis is a high-risk diagnosis, she is coding incorrectly. Some visits may require less documentation and intensity even if the diagnosis is complex, while others might require more than expected, depending on the patient’s other conditions.

The bottom line: The answer to which E/M code to report lies in the documentation, and nowhere else. Always code to meet your documentation rather than coding based on the diagnosis.