Pediatric Coding Alert

Question: One of our young patients was just hospitalized for acute gastroenteritis and dehydration. The patient was placed on intravenous (IV) hydration, but after the patient stabilized, she refused oral intake. Our pediatrician visited the patient a day after she was admitted, conducted a brief interval history and a limited examination of the patient’s gastrointestinal (GI) system. Then, after reviewing a small amount of data, our provider ordered more IV fluids without additives.

What would be the most appropriate evaluation and management (E/M) code to use in this encounter?

New Hampshire Subscriber

Answer: This particular scenario requires you to use a code from 99231-99233 (Subsequent hospital care, per day, for the evaluation and management of a patient …). Choosing the correct code will depend on the interval history, examination, and medical decision making (MDM) levels your pediatrician performed while treating the patient.

The interval history (basically, a history of the patient’s condition without a record of the patient’s past family and social history, or PFSH) in this encounter does not rise beyond problem focused, the lowest level of history for 99231-99233 services. The single-system exam, too, would only be regarded as problem focused.

As for MDM, two out of the three components (number of diagnoses/management options; amount or complexity of data to be reviewed; or risk of complications and/or morbidity or mortality) need to be present to determine the level of MDM complexity. The refusal of oral intake along with the GI issues would be considered a low-risk problem (two self-limited or minor problems), while the IV order reflects a low-risk management option in the table of risk pertinent to MDM.

That means your pediatrician’s MDM also only rises to low for the service. Given that two of the three subsequent hospital care E/M components only meet the lowest level of the service, and that you need two of the three to meet or exceed the requirements to qualify for a particular level, in this encounter you can probably only justify 99231 (Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A problem focused interval history; A problem focused examination; Medical decision making that is straightforward or of low complexity …).