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Code This!

Scenario Week of April 11, 2013:
View Current Scenario

Assign the Correct ICD-9-CM Diagnosis and CPT Diagnosis and Procedure Codes for the Following Coding Scenario.

The consultation for this three-year-old male patient is provided at the request of his pediatrician. He is accompanied by his mother. He has a history of chronic bilateral otitis media and middle ear effusions treated multiple times with antibiotics. The most recent course was otitis media one month ago, and he finished the antibiotics approximately 17 days ago. He also has a history of mouth breathing, and his mother states he has associated snoring and there is concern that he also has sleep apnea.

No history of heart or respiratory, gastrointestinal, or urinary problems. The patient has no known allergies, no current medications, no prior surgeries, immunizations are up-to-date, and no childhood illnesses reported.

The patient is exposed to some minor second-hand tobacco smoke, but not in his home. There are no pets in his home. Family history is significant for grandparents with diabetes, cancer, heart disease, and hearing loss, and his father has seasonal environmental allergies and is allergic to shellfish.

General: Happy boy who is a bit anxious to be in a physician’s office. Interacts well with me and has appropriate insight and answers for his age. He is well developed, well nourished, and has no apparent learning deficits.
Vital Signs: Temperature 99.1, Pulse 125, Respirations 27, Blood Pressure 100/65, Height 34 inches, Weight 35 pounds.
Ears: Well retracted and immobile. Bilateral tympanic membrane with effusions, no secretions, and no air flow.
Mouth: Normal oral cavity, tongue and floor of mouth.
Oropharynx: Tonsils are 2 to 3+ without exudate.
Neck: No nodes, masses or thyromegaly.
Cardiac: Regular rate and rhythm, no murmurs.
Respiratory: Clear with rare rhonchi.
Neurology: Nonfocal

Impression:
Chronic Eustachian tube dysfunction
Chronic/recurrent otitis media with effusion
Adenoid hypertrophy

Recommendations:
Discussed surgical options for long-term care including bilateral adenoidectomy and myringotomy with PE tubes. The risks and benefits of surgical procedures were discussed with the mother. We discussed postoperative complications and care. I answered all of the mother’s questions. She desired to discuss the options with the child’s father and the pediatrician at their next appointment. A copy of this consult will be sent to the pediatrician. If the mother agrees with surgical treatment, she will call and set a surgical date with the office.

Assign the appropriate ICD-9-CM and CPT diagnosis and procedure codes, as appropriate:


Coding Answers

ICD-9-CM Codes

381.81 Dysfunction of Eustachian tube
381.3 Other and unspecified chronic nonsuppurative otitis media
474.12 Hypertrophy of adenoids alone

Rationale

The dysfunction of the Eustachian tube is reported with code 381.81. There are no specific considerations for the dysfunction to be chronic or acute. The main term identified in the index is dysfunction with the subterm Eustachian tube. The code 381.81 is verified in the tabular listing.

The term otitis is referenced in the index. The subterm media includes additional subterm chronic and with effusion with a reference to 381.3. Verification in the tabular list indicates that 381.3 is correct and includes the note that it should be used to report chronic otitis media, specifically when it includes effusion.

Code 474.12 is used to report the hypertrophy of the adenoids. The term alone is used to indicate that it is not concurrent to tonsillitis. The main term accessed in the index is hypertrophy and the subterm of adenoids is referenced. If you included tonsils you would have the incorrect fourth and fifth digits.

CPT Codes

99243 Office consultation for a new or established patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

To document this visit as a consult, the provider meets the CPT consultation definition by including the following elements:

  • Provided at the request of another physician or appropriate source
  • Recommend care for a specific condition
    OR
  • Determine whether to accept ongoing management of the specific condition
  • Report sent back to requesting provider

Although the recommendation was for surgical intervention, the documentation meets the criteria of recommending care for the condition, as well as the determination that the provider would accept the patient for continuing care.

The history level is detailed. The chief complaint of the recurrent otitis media is there with the adenoid hypertrophy. The HPI is four plus, the review of systems is 2-9, and there is past medical, family and social history. As the review of systems was not 10+ it does not meet the criteria for Comprehensive. However as the presenting problems mainly affect the head and oropharynx there is no medical necessity to do a complete review of systems.

The exam is of six areas:

  • Constitutional
  • Ears/Nose/Mouth/Throat (E/N/M/T)
  • Cardiovascular
  • Respiratory
  • Psychiatric
  • Neurology

The exam for the E/N/M/T and constitutional was in more detail and this exam could be considered to be a detailed exam.

The medical decision making would be moderate. The number of diagnoses and/or management options would be multiple as there are three new diagnoses without additional workup. The amount and/or complexity of data is minimal or none. The Table of Risk is moderate with elective major surgery with no identified risk factors.

For outpatient consultations, codes 99241–99245, the three key elements must be met. With a detailed history, detailed exam, and moderate medical decision making, the appropriate code would be 99243.

If the payer follows Medicare guidelines and chooses not to recognize consultations, this service would be a new patient exam coded as 99203.

99203 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; a detailed examination; Medical decision making of low complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent face-to-face with the patient and/or family.

 
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