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Pediatric Coding Alert

Choose the Correct E/M Level to Optimize Reimbursement Ethically

Pediatricians who see four to six patients an hour may think they dont have time to calculate the appropriate level evaluation and management (E/M) service for every visit. But choosing the right E/M level may be the most important thing you can do for your bottom line. Unfortunately, many pediatricians undercode because they think it will protect them from audits. And they also do it for a more troubling reason: They lack the self-esteem to code what their services are worth, says Peter Rappo, MD, FAAP, assistant clinical professor of pediatrics at Harvard University School of Medicine and a practicing physician with Pediatric Associates of Brockton, in Brockton, Mass.

CPT Codes offers clear guidelines for selecting an E/M level, which allow you to base coding decisions on objective criteria, not a vague estimation of the value of your work. Following these guidelines will provide a solid defense against audits while optimizing reimbursement.

Pediatricians should select E/M levels using the elements with which they are already familiar: history, examination and medical decision-making. Understanding the factors that determine the level of these individual elements not just the E/M codes themselves will allow coders to mix and match elements to arrive at the appropriate E/M level for all established patient office visits (99212-99215).

Know the Requirements of Each Level of Element

The elements of history and exam can range from problem focused (the lowest level) to comprehensive (the highest level). Medical decision-making likewise spans four levels, ranging from straightforward to highly complex. Each level of each element must meet the following criteria:

History
Problem-focused
Chief complaint
Brief history of present illness

Expanded problem-focused
Chief complaint
Brief history of present illness
Problem-pertinent system review

Detailed
Chief complaint
Extended history of present illness
Problem-pertinent system review with an additional review of a limited number of additional systems
Pertinent past, family, and/or social history directly related to the problems discussed

Comprehensive
Chief complaint
Extended history of present illness
Review of systems related to the present illness plus review of all additional body systems
Complete past, family, and social history

Examination

Problem-focused
Limited examination of affected body area or organ system

Expanded problem-focused
Limited examination of affected body area or organ system and other symptomatic or related organ system(s)

Detailed
Extended examination of the affected body area(s) and other symptomatic or related organ system(s)

Comprehensive
General multi-system [...]