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Pediatric Coding Alert

Documentation of Time Is Critical When It Comes to Time-Based E/M Coding

Remember to summarize what was discussed during counseling.Pediatricians may spend more time counseling/coordinating care with patients than almost any other specialty, which means that your practice frequently bases E/M codes on time spent with the patient. But coding based on time can be a challenge if you don't know the three requirements of billing this way. Check out our quick primer to avoid having to send your E/M pay back to your insurers.Case in point: See if you can spot the problem with this chart entry:A 12-year-old girl seen for ADHD (chief complaint) FU (HPI-duration) visit. She has been on stimulant medication (HPI-modifying factor) for one month (HPI-duration) but is not doing well (HPI-quality). She is still having problems paying attention at school (social history-education) and with hyperactive behavior at home (HPI-severity). Her parents have not noted problems with appetite (ROS-constitutional) or sleep issues (ROS-neurological or respiratory-not both). Physical examination [...]

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