# Presenting Problem - A patient presents with ear pain



## Samantha68516 (May 9, 2013)

Is it true that the nature of the presenting problem should be the driving factor for E/M selection?

Example:

A patient presents with ear pain, runny nose, and fever.

HPI:  3 year old here today because he has been having ear pain and an ongoing fever for 4 days. Mom has been giving the patient Tylenol for fever. The patient has also had a runny nose.

ROS:  Constitutional: Fever for 4 days.
          ENT:  Ear pain and runny nose.

Exam:  General: Crying and holding right ear.
           Eyes:  Tears but not injected.
           ENT:  Right TM:  Bulging, with purulent drainage.
                    Left TM:  Inflamed, swollen, tender.
                    Nasal: Clear drainage present.
           Respiratory:  Clear to auscultation, no wheezing.
           Skin:  Clear, pink, no rashes.

Assessment:  Acute, Suppurative Otitis Media
                    URI

Plan:  Prescription of Amoxicillin for ASOM, and supportive care for URI.  Return if symptoms persist or worsen.


Please provide input regarding the E/M level selection for the above example, and information on presenting problem being the driving factor of selecting and E/M level.

Thank you!

Samantha


----------



## ashack63 (May 9, 2013)

Samantha68516 said:


> Is it true that the nature of the presenting problem should be the driving factor for E/M selection?
> 
> Example:
> 
> ...



Medical Necessity is ALWAYS the driving force in E & M level selection. 
Just to put it out there.... 
Is this a New or Established patient?
Medical Decision Making is Moderate on this... do you have an audit template?


----------



## MikeEnos (May 9, 2013)

I agree, the *medical necessity* is the over arching criterion for payment, and it should be the driving factor in determining the E/M level.  In other words, your provider might always document a detailed history and exam, but that doesn't mean every encounter qualifies as a 99214, even though you satisfy 2 of the 3 key components.  The medical necessity must support the level of service billed *(note that medical necessity is not synonymous with medical decision making)*

Regarding your question, the nature of the presenting problem is important, but it's just 1 of the 3 possibly ways of determining the risk.... which itself is just one of the 3 components of the overall medical decision making complexity.  

Looking at the example you posted, I would call that a *99213*.  There is no PFSH, so the *history is Expanded Problem Focused*.  The *exam is **Detailed* (at least in my region, it just barely qualifies as 5 organ systems - your local carrier may call it Expanded Problem Focused), and to my view the *Medical Decision Making Complexity is LOW* (not moderate.)  I call that diagnosis 2 self limited/minor problems (Dx - 2) no data (Data - 0) and overall risk of moderate (Rx drug management) which calculates to Low MDM using the Marshfield clinic guidelines.  This satisfies all of the requirements of a 99213.


----------



## MikeEnos (May 9, 2013)

Hi Samantha,
A diagnosis can either be self-limited/minor (worth 1 point in MDM-A) OR it could be considered a new problem with no additional work-up planned (worth 3 points in MDM-A)  but it can't be both.  I thought both of the diagnoses in this case (URI and Otitis Media) were 1-point problems.  There's a lot of grey area there and subjectivity, so if you were to feel that it was a 3-point problem I would defer to the physician on that one to see how they felt, since it is their NPI on the claim after all.

To answer your other question - yes the HPI, ROS, and exam should be medically necessary - so it should be pertinent to the problem.  HOWEVER, you must be very cautious when you are trying to determine what portions of the history or exam were necessary.  If you start arbitrarily deciding not to count things because you don't feel it was pertinent, you may find yourself at odds with a physician who has MUCH more clinical knowledge and medical training than you.  Generally I'd advise you to just score what is documented, there is no cause for concern unless the history and exam consistently far outscore the medical decision making complexity... but like I said in my last post, medical decision making IS NOT the same as medical necessity.


----------

