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Pediatric Coding Alert

Reader Question:

Diagnosis is Related to E/M Level, But Doesn't Dictate Code

Question: Our pediatrician saw an established patient with severe chronic allergies. The patient did not present with any symptoms currently, but the doctor documented a detailed history, a detailed exam, and low complexity decision making and circled 99214. Is this possible for a visit where he was just managing a previously-diagnosed condition? Maryland SubscriberAnswer: If the documentation meets the criteria for 99214, you can report it. According to CPT® rules, you need two out of three elements to support an established patient E/M service. In this case you have a detailed history and a detailed exam, which support a level-four office visit code, as long as there is medical necessity for a level-four established visit.Important: Medical necessity must support the level of your coding. With this patient, due to his severe chronic allergies, the physician would be justified in performing a detailed exam and detailed history even though his medical [...]

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