Take a Deep Breath When Seeking Reimbursement for Pediatric Asthma
Published on Mon Oct 01, 2001
Pediatric asthma is being treated more frequently by pulmonologists as well as allergists. According to Dr. Miles Weinberger, professor of pediatrics and director of the Pediatric Allergy and Pulmonary Division of the University of Iowa Hospital, this condition affects 15 to 25 percent of all children and accounts for 15 percent of their nonsurgical hospitalizations.
Coding for pediatric asthma is complicated not only by the age of the patient but because it cannot be diagnosed before the age of 2 or 3. The first year or two is spent monitoring and recording the child's symptoms. Only after repeated episodes of chest symptoms can the condition be diagnosed.
History, Decision-Making and Severity Affect E/M Coding
A 3-year-old boy presents to the pulmonologist after repeated episodes of wheezing, coughing, shortness of breath, and tightness in his chest. His visit is coded with E/M codes 99201-99205 if he is a new patient, 99211-99215 if an established one, or 99241-99245 if the physician has been called in as a consultant.
"Although any level of these E/M codes can be used, this visit will probably be coded higher rather than lower," Weinberger says. Both the severity of the presenting problem -- the compromised respiratory function of a child -- and the complex level of decision-making indicated by the battery of diagnostic tests that will need to be ordered may support a higher-level E/M code.
The extent of the medical history required also supports coding at a higher E/M level. According to Dr. Linda Ford, recent president of the American Lung Association and director of the Asthma and Allergy Center in Papillion, Neb., the medical history of the child plays the most important role in the initial diagnosis of pediatric asthma and must be comprehensive in detail.
"The history is usually extensive because it is important to establish the timing of the symptoms in relation to seasonal patterns and exercise in addition to obtaining a family history indicating a susceptibility to asthma," Ford says. While parents provide this information for very young children, she says it is important to have older children provide their own information. "Older children sometimes give different information than their parents, especially about wakefulness at night," she says.
Because the history is so important in diagnosing this condition, practices must make sure the documentation supports the amount of information obtained and the effort spent on the patient to ensure fair and complete reimbursement.
Determining the Most Appropriate Diagnosis
The physical examination of the patient concentrates on the lungs, upper airways, eyes, ears, nose (particularly the nasal passages) and throat. However, since the caliber of the airways cannot be estimated or evaluated from this information alone, spirometry (94010) is performed to supply the objective assessment needed for [...]
