Pediatric Coding Alert

Question: How would you level this office/outpatient evaluation and management (E/M) encounter?

A 5-year-old established patient came back with his mother for a follow-up after our pediatrician noticed a heart murmur during a previous visit and ordered an electrocardiogram (ECG). The test results came back with normal readings. The pediatrician noted they had reviewed the test and previous records. The pediatrician considered, but decided not to pursue, subacute bacterial endocarditis (SBE) prophylactic antibiotic therapy for the patient. The pediatrician provided a diagnosis of a benign flow murmur and cleared the patient for regular cardiovascular activity.

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Answer: Given what the pediatrician has documented, the likely office/outpatient E/M level for this encounter is 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making …). Here’s why.

Number/complexity of problems addressed: At best, you can regard a benign flow murmur as a stable chronic illness, which means this medical decision making (MDM) element only rises to a low level.

Amount/complexity of data reviewed: This element provides the gray area in the scenario. The ordering and review of the normal ECG would provide only one data point here, giving you a level of minimal or none. But the level could rise to moderate if the pediatrician’s documentation noted that the review of previous records included a review of prior external notes. Additionally, the patient’s mother could likely be regarded as an independent historian in this encounter given the patient’s age. However, without documentation to that effect, you will not be able to count her contribution to the encounter as an element of MDM.

Risk of complications/morbidity of patient management: Given the pediatrician considered, and ultimately rejected, SBE prophylactic therapy for the patient, you could argue that this is a management option. If so, then this MDM element could possibly be seen as moderate. However, as the other two MDM elements only meet the low or minimal/limited levels, the MDM level for this encounter only rises to the low level, hence the 99213.

But this encounter would be a great opportunity for provider education on how you arrive at an E/M level, as a moderate level of data in this situation could enable you to code 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a … moderate level of medical decision making …).