Opt for a monthly training session using this quick quiz with talking points instead. Don't Overlook History, Exam Elements Your office could be sacrificing $30 for visits that really are 99214s (established patient office visit). Pediatricians often perform history and examination elements but fail to record that information. Pediatricians may not realize that jotting down these details could justify a 99214 instead of the safety of CPT 99213 . Document This Doctor's Work Have the pediatricians who choose the levels, the MAs who write the CCs, the coders who perform chart audits, etc., see what information is missing from the following documentation:
Example: A 2-year-old child presents with a chief complaint of cough, cold and fever that the MA records. The pediatrician comes in and asks:
how long the symptoms have lasted including the fever's degree and duration and any nasal drainage's color
if the child's throat seems to hurt
if the child seems worse at any times
how much the child is fussing
if he has been screaming. The physician asks the parent if the child is pulling at his ears. He inquires about: how the child's cough sounds
how his appetite has been
if he has had any vomiting or diarrhea
if anyone else in the family has been sick
if the child is in day care
if the child has had these symptoms before. The examination includes looking at the ears; checking the head, nose and throat; palpitating the lymph nodes; listening to the chest; and probing the belly.
Documentation reads: Child here today for fever and congestion of two days, worse at night. Pulling at ears and eating poorly. Hearing appears fine. Tympanic membranes bulging and red. Ear purulent. Chest clear. Wrote prescription. Recommended FU in 10-14 days, sooner if symptoms not improving.
Codes selected: 99213, 382.00 (Acute purulent OM). Capture Work With History Breakdown If the pediatrician recorded these details, she should have turned the above chart note from 99213 into 99214 (fill in the blanks):
Hint: Remember to capture all the pediatrician's work with this template.
S CC: _____________________________________
O _________________________________________ Action: Discuss everyone's answers. Some questions you can pose: What history questions did the pediatrician ask but fail to record? What exam elements did the pediatrician check but not include in the documentation? Did the template help staff remember all the possibilities? Discuss These Performed, But Overlooked Items Using a template would have helped the MA and pediatrician remember to record:
S CC: fever, congestion
HPI: severity (screaming), fussiness, associated symptoms: [...]