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Coding Tips for Pediatricians Evaluation and Management Coding Strategies

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Coding Tips for Pediatricians: Evaluation and Management Coding Strategies

 

Pediatricians, probably more than any other primary care specialty, spend considerable time dealing with families with regard to a number of health-risk issues such as obesity, developmental concerns, as well as spending time with patients with special health care needs. Unfortunately, families have many dysfunctional issues that create a large amount of time in a pediatrician's office.

Calculate your practice’s evaluation and management (E/M) services here.

For most E/M visits, time will not be the key factor in determining the level of service that is used, although it is certainly an important factor for many E/M codes. If time is not the key factor in determining the level of E/M service, one does not need to document and determine the amount of time that is spent with the patient and/or family.

Many pediatricians forget that the additional time spent with patients may change the level of coding that is used. Current Procedural Terminology (CPT®) has long-standing specific guidelines for using time as a key factor in determining the level of evaluation and management (E/M) service. These guidelines are listed in the beginning paragraphs of the E/M section of CPT.

First of all, one needs to remember the key factors in determining the level of CPT code. The key factors include history, physical examination, and medical decision making for the service. The level of selecting most E/M codes will be determined by these three key factors. However, time becomes the key factor when the counseling, coordination of care, or both account for more than 50% of the face-to-face time with the patient and/or family. When this situation occurs, it is necessary to enter the total duration of counseling and/or coordination of care into the clinical notes, as well as a description of the counseling and/or coordination of care that took place. For example, if a detailed history and examination are performed, decision making is of low complexity, and 60 minutes are spent with the patient, 40 minutes of which are spent counseling the patient, the visit is coded 99205 (which CPT guidelines indicate has a 'typical' time of 60 minutes) rather than 99203 (which CPT guidelines indicate has a 'typical' time of 30 minutes), for a new patient. This is because the 40 minutes of counseling comprise 66% of the total time (60 minutes) spent with the patient. Since this percentage is greater than 50%, the physician would be correct in using time as the key factor for determining the level of service.

Key Factors that Influence E/M Coding for an Established Patient
CPT CODE99212992139921499215
HISTORY

Problem-focused

CC

Brief HPI

Expanded-problem focused

CC

Brief HPI

Problem Pert.

ROS

Detailed

CC

Ext. HPI

Ext. ROS

Pertinent PFSH

Comprehensive

CC

Ext. HPI

Complete ROS

Complete PFSH

PHYSICAL EXAMProblem-focused
Expanded-problem focused
DetailedComprehensive
MEDICAL DECISION MAKINGStraightforwardLow complexityModerate complexityHigh complexity
TIME*10 min.15 min.25 min.40 min.
  *Time becomes the key factor when counseling, coordination of care, or both account for more than 50% of the face-to-face time with the patient and/or family

For office and other outpatient visits, face-to-face time is defined as the amount of time the physician actually spends in the room with the patient. It does not include nurse time in activities such as preparing the patient or giving injections.

In the descriptors of the E/M codes, the specific times listed are averages of the time it takes to provide a particular service. The actual time it takes to provide a particular service may actually be higher or lower depending on the actual clinical circumstances. CPT has used these times based on studies that were performed to identify average amounts of time it took a physician to provide all components including pre-service, intra-service, and post-service of an E/M visit.

Some services the pediatrician performs do not require the presence of the patient. These include reviewing records and tests, arranging for further services with other health care professionals in coordinating care, and communicating with other health care professionals and the patient through written reports and telephone calls. It is important to remember that both face-to-face and non-face-to-face services have been included to help identify the average time an E/M service should take. The times indicated in the code descriptors are not usually intended to be used to select the level of E/M service reported because the E/M codes are generally chosen according to the key factors for the service. The exception to this rule, as noted above, is when counseling and/or coordination of care dominate the visit. This includes time spent with those who have assumed responsibility for the care of the child, whether they are family members such as the child's parents or foster parents, or legal guardian. The following is a list of the key factors that influence E/M coding for an established patient:

Pediatric Vignette:

A 2-year old child comes into the office for a sick visit and is diagnosed with otitis media. The history, physical examination, and medical decision making would qualify for a 99213 level of E/M code. However, the mother requests counseling from the pediatrician because of an upcoming divorce and current marital problems and the effect these have on her children. A total of 10 minutes was spent on history, physical exam, and medical decision making for otitis media, and 15 minutes were spent on counseling. A total of 25 minutes was spent during the visit of which greater than 50% was spent on counseling. This would then qualify for a 99214, based on time as the key factor. It is important in this case to use the ICD-9-CM code for otitis media (382.9) and also for family disruption (V61.0).

It is also important to remember that the time spent counseling can be time spent with the patient and/or family. There are many times the parent will come in to see the pediatrician without the child. The pediatrician can report this E/M service, using time as the key factor, even if the patient is not present.

Documentation is the key to using time as the key factor in determining the appropriate level of E/M code. One not only documents all the time components but the summary of the items discussed during the visit.

Pediatricians can improve their reimbursement by properly using time in many encounters that they have with their patients. It is something that general pediatricians use in their practices on a daily basis. Be sure to completely document all these services.


The recommendations in this publication do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate. This content is for informational purposes only. It is not intended to constitute financial or legal advice. A financial advisor or attorney should be consulted if financial or legal advice is desired.

 

 CPT Copyright 2012 American Medical Association. All rights reserved.

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