ED Coding and Reimbursement Alert

In the October 1999 ED Coding Alert, the article E/M Coding Clinic: Correctly Reporting 99283 vs. 99284 Means Understanding the History and Physical, page 7, contained a confusing clinical example in the last section. In that paragraph, we detail the case of a patient who has fallen and is suffering from hip pain. The patient also has uncontrolled hypertension.

In the article Pat Moore, vice president for reimbursement for Healthcare Business Resources Inc.,
an emergency medicine billing company in Durham, N.C., states:

The hip pain may be a fracture, and there may be
a bleed in patients with hip fractures so you need to
see them urgently. And, the hypertension can
complicate treatment.

Following her statement, we indicated that the additional problems could bring the visit up to a level 4 E/M (99284, emergency department visit for the evaluation and management of a patient, which requires a detailed history; a detailed examination; and medical decision making of moderate complexity). In fact, the uncontrolled hypertension may need to be treated more aggressively with medication, and, if the hip was indeed fractured, the treatment provided would be of higher risk. So, it is possible this scenario could even be a level 5 visit, depending on the individual clinical circumstances.

The overall take-home message from that section is that severity of presenting illness is not necessarily a good indicator of the appropriate E/M level to assign. Sometimes, a patient with a presenting complaint of seemingly low severity can have complications or additional clinical issues in the visit that would raise the E/M level.