ED Coding and Reimbursement Alert

Test your knowledge with this real-life scenario

Think you know when to report a level-two emergency department (ED) visit instead of a level-three? See if you can report the correct evaluation and management (E/M) code (99281-99285) for this patient.

The ED physician's notes say the following:

Presenting complaint: Patient "thinks she has the flu."

History of present illness: 45-year-old male, generally healthy, has been sick for three days with fever, chills, cough, headache, and body aches. T to 103. Cough nonproductive. No GI symptoms. Two other family members with similar symptoms. Nonsmoker.

Physical exam: T 102 other VS OK. HEENT (-) Neck supple; Chest clear; Heart and Abdomen (-).

ED course: Patient examined. Given ibuprofen, 400 mg. Does not appear to have pneumonia or a CNS infection. I think this is influenza. Too late for specific antivirals.

Disposition: Home rest and fluids. Tylenol or ibuprofen. Recheck for persistent or worsening symptoms.

Diagnosis: Influenza.

Should you describe this scenario with 99282 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of low complexity) or 99283 (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity)?

Solution: The most appropriate code for this case is 99283. Most often, in cases like this that may require a level-two or a level-three, the deciding factor is medical decision-making (MDM) - not history and physical - says Robert LaFleur, MD, FACEP, president of Medical Management Specialists in Grand Rapids, Mich.

"Since there are no tests done and no data to review, you're left looking at 'presenting problem' and 'management options' in the risk category, and then at 'number of diagnoses or treatment options' in the remainder of the MDM grid," LaFleur says.

Even if you assume that the management options in this case entailed no more than low-risk factors, the patient still has an acute illness with systemic symptoms. "That is moderate risk in that area, and according to the Table of Risk in the Documentation Guidelines, would make the overall risk also moderate," he says. The documentation guideline rule for the table of risk is that the highest level of risk in any one category (presenting problem[s], diagnostic procedure[s], or management options) determines overall risk.

Reason: The guidelines for selecting the level of MDM state that the physician's documentation must meet or exceed the requirements to satisfy two of these three elements of MDM to achieve a given level:
 

the number of possible diagnoses and/or the number of management options the physician must consider

the amount and/or complexity of medical records, diagnostic tests, and/or other information that the physician must obtain, review and analyze

the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

If "risk" is moderate and "data to review" is minimal, it would take multiple diagnoses and/or treatment options in the "diagnosis and treatment option" area to make the overall MDM moderate - and for the case to warrant 99283. "For that to happen, all that's necessary is for the presentation to be a 'new problem' with no additional workup planned," LaFleur says. "I think that fits."

"Due to the scope of different diagnostic possibilities, and the fact that she is a new patient, I would report a
level-three," agrees Sharon Clement, CPC, business manager of the ED physician group in the Norwalk Hospital Emergency Department in Norwalk, Conn. "I see the risk as moderate."

While ED coders tend to gravitate toward prescription drug management in the risk table as an easy way to establish the risk as moderate, the column for "presenting problem" can also help guide your code selection. In this patient's case, "acute illness with systemic symptoms" would qualify the MDM as moderate.

Counterexample: A similar patient presents to the ED with an isolated earache or sore throat. The physician gives her over-the-counter medications and does not perform any tests. This patient's E/M only warrants a  level-two (99282), LaFleur says. The level-three patient's condition involved multiple and systemic symptoms, which require a higher degree of MDM.

In the example cases in the back of CPT, the 99282 cases are mostly localized problems: sunburn on back, impetigo on face, cystic lesion on back, drainage from eye. The 99283 cases, on the other hand, include minor systemic illnesses, such as "well-appearing 8-year-old with fever and diarrhea." This last example, because it is multi-systemic, falls closest to the patient's chart above.