# e/m coding. im so confused



## NJcoder (Mar 17, 2011)

when figuring out the History part of a ER level how do you know the difference between level 2 and 3 when both are Expanded Problem Focused (EPF)??


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## jimbo1231 (Mar 17, 2011)

*Mdm*

The difference is Medical Decision Making not History and Physical.. MDM is moderate for 99283. Although you can't use clinical examples as a basis for coding, take a look at the clinical examples in the back to get a feel of the 99282s vs. the 99283s. Usually with a 99283 a prescription or a diagnostic will get MDM to a 3.

Jim


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## NJcoder (Mar 17, 2011)

But don't you have to come up with a level for History then Exam then MDM in order to come up with the proper level?


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## coder671 (Mar 17, 2011)

NJcoder said:


> But don't you have to come up with a level for History then Exam then MDM in order to come up with the proper level?



Obviously people are taught different ways, but the way I was taught was to establish what level of history is present, what level of exam is present, what level of MDM is present and then find the highest level of service for which they will qualify. Since an expanded problem focused history and an expanded problem focused exam will qualify as high as 99283, your next step should be determining if the medical decision making is of moderate complexity or higher. If it is, you have yourself a 99283. If it's not, then you would start to look towards the lower levels of service.


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## NJcoder (Mar 17, 2011)

Ok, i'm confused because i'm studying for cedc exam and trying to come up with the History level and these are the options: Level 1 is Prob. foc. Level 2 is EPF Level 3 is also EPF.  Whats the difference between Level 2 and Level 3? Thanks


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## coder671 (Mar 17, 2011)

NJcoder said:


> Ok, i'm confused because i'm studying for cedc exam and trying to come up with the History level and these are the options: Level 1 is Prob. foc. Level 2 is EPF Level 3 is also EPF.  Whats the difference between Level 2 and Level 3? Thanks



There is no difference between the 99282 and 99283 history and exam elements. The same expanded problem focused history and expanded problem focused exam will qualify you for either 99282 or 99283. *The only difference is the MDM. * I think you are making this harder than it actually is.


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## btadlock1 (Mar 17, 2011)

NJcoder said:


> Ok, i'm confused because i'm studying for cedc exam and trying to come up with the History level and these are the options: Level 1 is Prob. foc. Level 2 is EPF Level 3 is also EPF.  Whats the difference between Level 2 and Level 3? Thanks



You might find this page helpful: http://www.fpnotebook.com/Manage/Billing/EmEmrgncySrvcs.htm
CPT Code 99282
Key Components (All 3 meet or exceed requirements)
  1. E/M Expanded Problem Focused History 
  2. E/M Expanded Problem Focused Exam 
  3. E/M Low Complexity Medical Decision 
 (Problem Severity)
  1. E/M Low Severity Problem 
  2. E/M Moderate Severity Problem 

 CPT Code 99283
Key Components (All 3 meet or exceed requirements)
  1. E/M Expanded Problem Focused History 
  2. E/M Expanded Problem Focused Exam 
  3. E/M Moderate Complexity Medical Decision 
  (E/M Moderate Severity Problem) 

As everybody else has mentioned, the difference between these boils down to MDM and Medical necessity (MDM and Med. Nec. are related, but not the same thing) 
Medical Necessity is based on the Nature of Presenting Problem (NoPP, for short, since I don't want to type it out...)
Minimal/minor/self-limited = Something that will probably go away on its own (eg, cold, bug bite) - minor problems don't have much risk, and deciding what the Dx and Tx plan doesn't take much thought, so these problems usually correspond with SF MDM.
Low = Acute uncomplicated illness or injury (allergic rhinitis, simple sprain, etc.) - Problems are more severe than 'minor', but still don't pose much risk. They may require more testing to rule out something more serious (eg, pneumonia, or a broken bone), and/or treatment by PT, IV fluids (only), OTC drugs, or minor procedures with no risk (sutures, simple closures). 
Moderate = The prognosis is uncertain, or has the potential to be bad enough to require eventually turn into a high severity problem. Acute complicated injuries are also in this category (head injury with loss of consciousness, colitis, pneumonia) - these problems may require more invasive or complex diagnostic procedures, and the treatment also carries its own risk (usually prescription drugs, or IV fluids with additives are involved, but other relevant examples for ED are minor surgeries with risk factors (minor outpatient surgeries, closed Tx of fracture or dislocation, w/o manipulation).
High Severity - they've practically got one foot in the grave, and need immediate treatment to save their life and/or bodily functions, OR the diagnostic or therapeutic procedures required for their problem are dangerous on their own (major surgery, diagnostic endoscopy/cardiovascular imaging studies with identified risks)

So if you're not sure if you should choose low or moderate, ask yourself these questions:
How bad is the problem (Does it require immediate care)?
What would likely happen if they didn't get treatment at that moment (or soon)?
What did the doctor have to do to find the diagnosis?
What is he doing to treat it? - Are there potential side effects/risks of either the Dx or Tx procedures?
Does the patient have any other problems that could complicate their presenting problem, its diagnostic procedures, or its treatment (eg, diabetics have more risk for infection w/open wounds)?

You can usually get an idea of how severe the problem is in the HPI and in the plan - (since that's kind of the point of HPI) - the plan is the most telling, though. If the doctor just said, "get some rest and fluids and FU w/PCP in a week if not better), it's probably low. If he prescribed something, scheduled a referral or urgent follow-up, gave a shot (antibiotic, tetanus, anti-emetic), or just seemed concerned in general, it's probably moderate.

Check the clinical examples in Appendix C of the CPT to get an idea of what kinds of cases are considered Level I, II, III, etc...

Hope that helps!


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## NJcoder (Mar 18, 2011)

All of you are so helpful.  And probably right, that i'm making this more difficult than it may be.

What tool did you use for the CEDC exam?  I will check out that website provided, thank you.


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## Mojo (Mar 18, 2011)

I used the tool that AAPC provided once I paid for the exam, Quick Reference Code Sheet by Stephaine L. Jones.

I also like the CMS audit tool:
https://www.highmarkmedicareservices.com/em/pdf/scoresheets/8985.pdf

I enlarged the table of risk because I am not a morning person and I needed all the help I could get!

Good luck! Did you purchase AAPC's ED Practicum?


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## jnwhite80 (Jun 29, 2011)

I think what is being asked is not about the E/M level but the level of the key component for History.

The history component consists of the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH) sections. A chief complaint should be documented for every visit often in the patient's own words. If the patient states “my back is killing me” for the first visit chief complaint, “follow-up for low back pain” might then be the chief complaint for a follow-up visit. 

The ROS is an inventory of 14 body systems focusing on a description of symptoms (chest pain or shortness of breath) rather than diseases (heart attack or COPD). The PFSH is a review of three areas: past history, family history and social history. 

It is important to know if the facility or physician is using the 1995 or 1997 CPT E/M guidelines when determining the E/M.

I hope this information proves useful.

Janice N White, RHIA, CPC, CTR


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