# Pediatric ER E/M



## DHirshfield (Oct 13, 2012)

Hello all.  I code physician reimbursement for a large physician group practicing at a children's hospital in a major city.  I am trying to gather information on what levels you bill at most frequently?  In specific, our leveling tool will place a conjunctivitis at 99284 because of meds prescribed with history given by parent and a comprehensive exam which our physicians do because many of these children do not have primary care physicians.  What we are trying to do moving forward is to get these to a 99283 with a problem focused exam.  I am trying to find out if there is a bell curve in your pediatric hospitals and if you would please share them.  Thank you, Debra


----------



## jimbo1231 (Oct 16, 2012)

*Most Frequently*

Hi Debra,

I understand your tool suggets 99284 based on the meds and the exam and history provided by parents. But with Emergency Mediicine although usually not programmed into coding tools, severity of presenting problem and the resulting medical necessity for the work up done fall into those gray areas that cannot be baked into EMRs or coding tools. Coming to the ED with symptoms of concunctivitis and meds prescribed is more like a 99283 than 4 in my view. If there were additional symptoms like fever and respiratory symptoms and more work up I'd be closer to a 4. But ED coding levels have been inching up for many years, and some will code a 4 for that. The argument that a more complete work up is done because the patient has no primary care doc doesn't necessarily justify a higher level.
Since Levels have been inching up for many years the old bell curve for ED levels is usually not the case for adult EDs, with 99284 usually the most commonly coded service. However pediatric EDs without a higher acuity Medicare population might be lower and closer to a bell curve at say 3.5. However I did pediatric ED coding and many kids with chronic problems that are exacerbated came to the ED which certainly increased acuity. But families using the ED as the doctors office will tend to lower acuity.
And a problem focused exam will not get you to a 99283, you need Expanded Problem Focused.

Jim


----------



## mitchellde (Oct 16, 2012)

I agree with Jim and would like to add that even though a complete exam is performed it does not necessarily count if the areas examined have no connection to the presenting problem.  Just because you can examine it does not mean it can be counted.  Also prescribing meds is only one out of 3 components of MDM and it takes 2 to be a level of MDM, again just because they list addition chronic issues does not mean you get an elevated number of dx reviewed.  and just because Mom is giving you the history does not give you elevated complexity of information, so for conjunctivitis .. with no other presenting problems in a child I have minimal dx, and complexity is minimal or at best limited even though risk is moderate so minimal, limited and moderate gives you low complexity MDM, so it is really a 99282  since you must meet or exceed all 3 key components.  
Just playing devils advocate on this!


----------

