Apply Sports Medicine Know-How to Your E/M Understanding - Pediatric Billing & Coding Alert
Discover how to apply sports medicine expertise to pediatric E/M coding with our latest insights.
Pediatric Billing & Coding Alert
With the school sports season on the horizon, pediatric coders should prepare for rising sports-related injuries among young athletes.
This is a prime opportunity to refine your understanding of key evaluation and management (E/M) elements, particularly within the context of musculoskeletal injuries.
During the presentation at HEALTHCON 2024, “Clinical Perspective of Sports Medicine Coding From an Athletic Trainer,” Nate Felt, MS, ATC, PTA, CPC, a senior consultant for orthopedic, sports medicine, and radiology coding at Intermountain Health in Salt Lake City, Utah, provided valuable insights into precise E/M coding for sports medicine. The session focused on the nuances of managing injuries such as sprains, strains, and minor fractures, ensuring accurate coding for diagnosis, treatment, and injury prevention.
Mastering the MDM Table
In non-surgical sports medicine, E/M services play a key role. Pediatricians are often the first to assess student athletes with injuries. During the initial visit, they conduct a medically appropriate exam, evaluate the condition, discuss prevention and treatment options, and either manage the injury or refer to an orthopedic specialist or athletic trainer. Pediatricians must thoroughly understand and document the key elements of medical decision-making (MDM) to ensure accurate coding.
Below are common scenarios pediatricians face and how to frame them within MDM elements.
Simple Sprains
Professionals and payers often see sprains as straightforward and categorized as acute, uncomplicated injuries. However, as Nate Felt emphasized, “I struggle with this terminology, and it’s interesting that the AMA includes sprains as an example. An ankle sprain is never simple.” Pediatricians and athletic trainers must treat ankle sprains correctly from the outset to prevent re-injury due to instability.
As Felt noted, accurate documentation is vital: “If the notes make it look like a simple ankle sprain, then it’s a simple ankle sprain.” Every individual is different. An active athlete who sprains their ankle is more prone to re-injury than someone less active. Thoroughly documenting the evaluation, management, discussions, risks, and patient-specific factors will support the appropriate level of care provided.
X-Rays and Double-Dipping
When leveling an E/M encounter, exercising caution with X-rays is important. X-rays generally do not contribute to the MDM score. For instance, if you order, perform, and bill for the X-rays, some providers may mistakenly believe they can also count the interpretation of the X-ray toward MDM. This practice, however, constitutes double-dipping, as the interpretation has already been billed separately. Avoiding this mistake ensures proper coding and compliance with billing guidelines.
Independent Interpretation
Consider a scenario where your pediatrician sends a patient for an MRI, and although the radiologist interprets it, the pediatrician is not fully confident in the findings. “They pull up the MRI images and conduct their official interpretation,” explained Felt. This approach could also apply to X-rays, but regardless of the imaging type, the documentation must be distinct, not a copy of the radiologist’s report.
It should reflect additional findings or indicate a substantially independent interpretation. If the documentation demonstrates this, “it could qualify for a level 4 in that middle [data] column,” according to Felt. Furthermore, if the first column’s criteria align with level 4, this independent interpretation could significantly impact the coding level.
External Physician Consults
If a pediatric patient suffers a borderline foot fracture, a pediatrician may refer the case to a sports medicine doctor. In some cases, the pediatrician might consult with an orthopedic surgeon, especially if they have significant experience with foot injuries. According to Felt, consulting with an external physician can contribute to your E/M level. “An external physician is not in your same specialty and not in your same group practice,” Felt clarified. To properly count this consultation toward the MDM, it’s essential to document these details accurately in the notes.
Independent Historian
The role of an independent historian should be considered. When a parent or guardian is present during the encounter and provides critical information, such as when a young athlete is unable to communicate due to injury, it can elevate the level of the encounter. For example, if a patient cannot relay the details of an injury and the parent steps in to provide a thorough account, this qualifies as an independent historian. This input can significantly enhance the complexity of the data reviewed, which is a key factor in determining the appropriate E/M level.
Be Thorough in Your Documentation
Payers review claims and attached documentation without necessarily having a clinical background. If something isn’t documented, it may as well not have occurred.
Felt emphasized the importance of clear and specific documentation, particularly in independent interpretation scenarios. For instance, if a pediatrician’s independent interpretation of X-rays or MRIs closely mirrors the radiologist’s report, the payer might not recognize this as a distinct independent review.
Felt advised documenting detailed findings to ensure proper credit: “I independently reviewed and interpreted X-rays and MRIs previously done by the radiologist. My findings align with the radiologist’s report, but I also identified dysplasia.” This level of detail ensures that the independent work is evident in the documentation.
Optimizing Pediatric Sports Medicine Billing with BillingFreedom
BillingFreedom excels in integrating sports medicine knowledge into pediatric billing and coding. We also have extensive experience in multiple fields in pediatrics, such as newborn billing. As discussed, precise documentation and understanding of E/M elements are vital, especially for managing sports-related injuries. Our expertise ensures accurate coding, from handling independent interpretations to managing consultations with external specialists. We meticulously document each detail, avoiding pitfalls like double-dipping and ensuring the proper recognition of independent historians.
In scenarios involving complex cases such as sports injuries, our team ensures that every aspect—from X-ray interpretations to detailed patient histories—is thoroughly documented. This rigorous approach not only supports correct coding but also maximizes reimbursement opportunities. With BillingFreedom, you gain a partner that applies deep sports medicine insights to streamline and optimize your billing processes, guaranteeing compliance and enhancing financial outcomes.
For more details about our exceptional pediatric billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
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