# Pharyngitis Level in the ER



## mtaftmtf (Jun 30, 2013)

Hi all new to ER coding, if a Pt present to the ER and is DX with Pharyngitis, with a detailed history, a Detailed exam, no workup, given a Rx and moderate MDM could that be a level 4 visit ? Thanks for your help.


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## mitchellde (Jun 30, 2013)

How do you get moderate MDM  with no work up and only one dx.  The prescription is moderate risk which is only one component of MDM. You need two out of three components so from what you describe it is straight forward MDM so it is a 99281 which is more on line with the patient's medical necessity


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## Mojo (Jul 1, 2013)

mtaftmtf said:


> Hi all new to ER coding, if a Pt present to the ER and is DX with Pharyngitis, with a detailed history, a Detailed exam, no workup, given a Rx and moderate MDM could that be a level 4 visit ? Thanks for your help.



We would assign 99283 for this type of visit: new problem, no additional workup, no data reviewed with a low moderate risk. If the Rx has a greater risk (narcotic), we assign a high moderate risk for a level 4.


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## mitchellde (Jul 1, 2013)

wait are you coding for the physician or the facility?


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## mtaftmtf (Jul 1, 2013)

mitchellde said:


> wait are you coding for the physician or the facility?



We are coding for physician services.


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## mitchellde (Jul 1, 2013)

I still see it as a level 1 and maybe stretched to a level 2 but no m,ore than that.  CMS has a recent bullkiten on E&M and the level of visit for physician billing.  They stress that medical necessity is the overarching criteria.  A pharyngitis with no other co morbid issues should be no higher than a level 2.  And I still say based on the info provided this is a level 1.  The risk is per the risk table and yes prescriptions is moderate, however 1 dx even as a new problem is minimal under dx and with no workup there is no complexity which is still straight forward MDM.


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## jimbo1231 (Jul 2, 2013)

*No work up?*

This is one where we might need to look at the chart, in theory. Was a Strep Screen done? Did the physician state why a prescription was ordered since prescription meds like anti-biotics are usually ordered if Strep is found or there is fever but not often if the patient had a basic sore throat. Were there additional symptoms like fever?
Hardly any ED visits are coded 99281 at this point. It is in the 1% range. I'm not advocating that. But generally if a person shows up at an ED unless they are there for a follow up, they are new to the providers and require a work up (still need to see what that was in our example but sounds like they did a decent history and exam), you are typically starting at a 99282. i'm not saying that 99281 should never be coded but it's a rarity. And the government will be focusing on the dramatic increases in 99285 over the last number of years  more so than 99281 and 2.

Jim


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## mitchellde (Jul 2, 2013)

I live in a city where a large portion of the population uses the ED like a primary care provider.  It is a large student population and they do not have a PCP, these patients go to the ER for everything from a a hangnail to heart attack.  So a level 1 in the ER is not as uncommon as it sounds.  I agree that a review of the document would tell us the true level, but given the scanty information provided I still see nothing better than a level 1.  But getting back to the presenting problem, with no other co-morbidity pharyngitis is justifiable as a level 1 encounter.


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## jimbo1231 (Jul 2, 2013)

*99281*

Michelle,

I think we are agreeing to disagree.  I can tell you that pharygitis is coded close to 100% of the time at least 99282. In fact I see it coded 99284 at times which I think is a stretch barring as you said something else going on and addressed. And of course we'd have to see the chart. If it is really sparse might be challenging to get to a 99282. 
But I would agree that with the student population and people using the ED as a doctor's office you would expect lower acuities. Isn't Obamacare going to fix all that....

Jim


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## mitchellde (Jul 2, 2013)

Yes without the chart note we shall live to disagree.  I too have observed this coded most frequently as a level 2 however many times the documentation did not support this level, again it comes down to the patient and did the provider adequately document the thought process, simple phayngitis should not be more than an ER level 1, however if the patient presented as possibly more than this but the workup did not reveal anything more serious then I can see a 2 or a 3, however when the poster states no work, then I am assuming a patient that has a sore throat and it is evening or weekend timefram and presents to the ER for what they hope is a script for antibiotics.  This is the picture I have given the sparse info provided.  
Truely I do not see Obama care "fixing " this scenario at all, until the docs want to have 24 hour offices and on demand appoints, the patient that waits until they can no longer tolerate the symptoms, and in their mind wants to be seen now right now will always be the present to the ER person and then complain about the length of time they wait to be seen.


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## mtaftmtf (Jul 2, 2013)

I thank you all for your input and I will post the entire note for this encounter minus patient information soon, again thank you for your input.


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## imomofbk56 (Oct 23, 2013)

I am going to have to agree with Mojo.  If you go to E/M University you will see that when doing the point system on the MDM it would make this a 99283.  It is 1 point for self limited and then most always a new patient in the ER which is a 3.  This one would be 1 point for self limited and 3 points for new problem no additional workup for a total of 4.  0 for no data and 3 for moderate on risk due to prescription.  Two out of three would equal a moderate.  Since this is detailed history, detailed exam and moderate I would code a low moderate at a 99283.


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