# An ED case that I'm struggling with



## MikeEnos (Jul 26, 2013)

I'm auditing an Emergency Department note that was billed as a 99283

The history is detailed
The exam is detailed
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At this point I already know that the code selection is wrong.  If the MDM is Moderate, this is a 99284, if it is low, this is a 99282, and if it is straight-forward then this is a 99281.

Here's where I'm struggling:

Diagnosis is Acute Otitis Media.  No labs or data are reviewed.  Antibiotics are prescribed.

This qualifies for Moderate risk (Rx drug mgmt), with minimal data, but how many points are assigned for the diagnosis of Otitis Media?  Is it 1 point, for a *self-limited or minor problem*, or is it 3 points for a *new problem to the examiner, with no additional workup planned*?  The decision makes a huge impact on the final code selection:

If you assign it as a self-limited or minor problem, then the overall MDM is Straight-Forward and this qualifies as a 99281

If you assign it as a new problem with no workup planned, then the overall MDM is Moderate, and this qualifies as a 99284.  That's a huge difference.

What do you folks think?  99281, or 99284?


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## jimbo1231 (Jul 26, 2013)

*Otitis*

Mike,

The choice should never be 99281 or 4. But documentation requirements do have their quirks. Unless the child had been in the day before with the same problem the ED visit in cases like these are correctly new problem no additional work up planned. I know some will disagree with this. But from an industry perspective 99281 is coded maybe at most 1% or the time and Otitis with meds certainly isn't an example. The choice I usually see is between a 99283 and 4. Some will code this a 4 based on the detailed H&P( pretty much all ED records these days get you the detailed H&P). Although not offically in your audit tool kit, I believe you have to factor in presenting problem and medical necessity. I would be at a 99283 for this one factoring in the presenting problem. But an argument can be made for 4 based strictly on guidelines.

Jim


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## ginalola77 (Jul 26, 2013)

Hi Mike,

I do ED coding for a mutli-ed hospital in CT.  The level of service is a level three.  99283 and 99284 both require mod-dm.  Ed pts are always considered to be new, so under :# of dx/management, it will either be a 3 or 4.  We consider admits/tranfers/or pt being referred for outside additional tests to be a 4.  Since this pt gets a three for # of dx/mang and moderate under the table of risk(rx given), the MDM is moderate.  You have to remember, all ED pts are new, not established.

Hope thsi helps,
Gina


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## ginalola77 (Jul 26, 2013)

If you have not been using all ED pt are new, your audit results will be way off!!!  If you ever need help, you can contact me.  I have been doing ED coding for 14 years.


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## Mojo (Jul 26, 2013)

99283

Deciding between 99283 or 99284 in the ED can make one's head spin. We split the moderate MDM risk into low moderate (99283) and high moderate (99284) with guidelines for each level for consistent coding.


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## MikeEnos (Jul 26, 2013)

Thanks for the feedback.  In many ways, I WANT to agree, but I need to be very factual in my audits... and it's very difficult to reconcile some of these recommendations with the guidelines.  If there is any way, I'd love some documentation that supports it.  

@Jimbo


> Unless the child had been in the day before with the same problem the ED visit in cases like these are correctly new problem no additional work up planned. I know some will disagree with this. But from an industry perspective 99281 is coded maybe at most 1% or the time and Otitis with meds certainly isn't an example. The choice I usually see is between a 99283 and 4. Some will code this a 4 based on the detailed H&P( pretty much all ED records these days get you the detailed H&P). Although not offically in your audit tool kit,* I believe you have to factor in presenting problem and medical necessity. I would be at a 99283 for this one factoring in the presenting problem.* But an argument can be made for 4 based strictly on guidelines.


In many ways I agree with you, but when I look at the CPT recommendations for a 99283, the Presenting Problem is supposed to be of Moderate severity.  The presenting problem for a 99284 is supposed to be High severity.  So using the presenting problem as your barometer, wouldn't you mark it down as a 99282 (Low to Moderate presenting problem severity) ?

@Gina


> The level of service is a level three. 99283 and 99284 both require mod-dm.
> .....
> Since this pt gets a three for # of dx/mang and moderate under the table of risk(rx given), the MDM is moderate


But since a detailed history and exam are documented, and you say the MDM is Moderate, you've just described the requirements for a 99284.... why do you say the code is 99283?


> Ed pts are always considered to be new, so under :# of dx/management, it will either be a 3 or 4


That seems true as a rule of thumb, but remember that self-limited or minor problems are 1 point whether they are new to the examiner or not.  They don't automatically count as new problems without additional workup planned (3 points.) 

@Mojo


> We split the moderate MDM into low moderate (99283) and high moderate (99284) with guidelines for each level for consistent coding.


I'm not sure if I absolutely love this idea or if it just complicates things more.... I suppose if it works for you and you're comfortable with it, that's all that matters.  My situation is more complicated, because I need to be able to show how I scored this note.


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## Mojo (Jul 26, 2013)

I have been fortunate to work with companies that have talented groups of professionals who make up their compliance committees. They have strict coding guidelines they are constantly tweaking for consistent coding. Each entity should have these protocols in place for their coders.

Splitting the moderate risk into low and high severity is only one component of the MDM. As Gina posted, ED visits are new problems to the examiner and you had no data to review.

Our comfort zone has nothing to do with our policies and procedures. Due to your complicated situation, perhaps a consultation with a professional firm such as BSA Healthcare would help.


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## jimbo1231 (Jul 27, 2013)

*Moderate Severity*

Mike,

The big problem you are facing is about the history of documentation Back in the early 90s when the vignettes were developed for the guidelines, a poor job was done representing EDs at the CMS/CPT table. So the 1995 guidelines were more about internists that have the luxury of time for complete ROSs etc than ED practice reality. Then the 1997 guidelines didn't have an Emergency Medicine guideline! I've often thought someone from ACEP must have really POd someone from AMA/CPT! So we all do the best we can with flawed guidelines for Emergency Medicine.
Having said all that, why would you think a kid reporting probably with ear pain, fever etc would not be moderate severity PP? Kids can be quite sick with an ear infection as I recall from a long time ago when my kids were in that phase.

Jim


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## MikeEnos (Jul 29, 2013)

That's true, maybe I'm too familiar with pediatrics charts where a routine otitis media case is a 99213 (low  MDM.)  Pediatricians would code 90% of the OM patients as a 99213 because it's so routine and straight-forward.  Only if it was a double ear infection, or if they were very sick (high fever, very fussy, etc) would they code that as a 99214, and documenting those symptoms would usually be enough to justify the moderate mdm and therefore 99214.

I agree with you that the guidelines do a poor job of describing an ED encounter.  It feels like trying to fit a square peg into a round hole!  I think I need to look beyond the 3 key components of History, Exam, and Medical Decision Making complexity.... I need to also consider the *severity of the presenting problem*.  So the Otitis Media patient who has a Detailed History and Exam, and Moderate MDM doesn't _HAVE _to be a 99284, I can agree that it is a 99283 based on the fact that the severity of the presenting problem is *moderate *(99283) and not *high *(99284)

Using that as my barometer, I am now finding that the level of ED visits now align with my "gut feeling" towards what it should be.  Before I felt like there was a gap between what I felt was appropriate, and what my audit template told me it was.  

As always, you have all been a big help - thanks very much.


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## saj402 (Aug 20, 2013)

ginalola77 said:


> Hi Mike,
> 
> I do ED coding for a mutli-ed hospital in CT.  The level of service is a level three.  99283 and 99284 both require mod-dm.  Ed pts are always considered to be new, so under :# of dx/management, it will either be a 3 or 4.  We consider admits/tranfers/or pt being referred for outside additional tests to be a 4.  Since this pt gets a three for # of dx/mang and moderate under the table of risk(rx given), the MDM is moderate.  You have to remember, all ED pts are new, not established.
> 
> ...



There is no distinction between "new" and "established" patients in the ED. See the first paragraph of the CPT book under Emergency Department Services.  It is not part of the code descriptor for 99281-99285.  There are three types of problems to the examiner - self-limited or minor, established, and new.  It is possible for the provider to be dealing with a self-limited or minor problem in the ED such as a cold, insect bite, rash.  The medical necessity would not warrant a detailed history or exam on such patients and in alot of cases otitis media would be considered a self-limited or minor problem.  Yes, the risk may be Moderate for the RX but if the problem to the examiner is self-limited or minor and you have no data points the MDM could be SF or Low.

thanks,
Sherry


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## FTessaBartels (Sep 12, 2013)

*Otitis Medea*

Speaking from the pediatrics side of the aisle ... OM is not considered a self-limited problem. It does not go away by itself, and if left untreated can lead to a burst ear drum and affect the child's hearing. 

In the ER, I would consider it a new problem w/o workup.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## CactusCoder (Sep 27, 2013)

Not to resurrect an old thread, but here is a description of AOM complications. Given this, it could indeed be considered a presenting problem of moderate severity, IMO. 

http://www.ncbi.nlm.nih.gov/pubmed/15967073


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