Pediatric Coding Alert

Question: A pediatrician documents, "12-month-old here for evaluation of cough and cold symptoms for two days. Mom heard wheezing today. Afebrile at home. No history of asthma." What history is this?

Michigan Subscriber

Answer: The documentation supports an expanded problem-focused history. Let's break the phrases into parts:

CC: Cough

Associated SS: Cold

Duration: Two days

ROS: One (constitutional-fever)

PFSH: One past medical (no history of asthma).

The associated signs and symptoms (SS) and duration fall under history of present illness (HPI). Therefore, you have two HPI elements.

You have one review of systems (ROS) and one past medical, family, social history (PFSH).

The 1995 guidelines classify these element amounts as follows:

• Two HPI is brief (one to three elements).

• One ROS is problem-pertinent.

• One specific item from any of the three history areas qualifies as pertinent PFSH.

An expanded problem-focused history requires you to meet all three elements of a brief HPI, a problem-pertinent ROS and no PFSH. So your documentation supports, even without the asthma history, an expanded problem-focused history, which could indicate a level-three established patient office visit code, provided medical necessity calls for an expanded problem-focused examination and requires low-complexity medical decision-making.