ED Coding and Reimbursement Alert

5 levels of NOPP don't always line up with ED E/M.

If you don't have a firm grasp on nature of presenting problems (NOPP) levels, you won't be able to choose the most accurate ED E/M code possible for each claim.

Why? It's the lynchpin in deciding medical necessity for an E/M service; without accurate NOPP level, you cannot decide on medical necessity for the encounter.

"Medicare and insurers will only reimburse for care that is 'medically necessary.' CPT defines medical necessity by the nature of the presenting problem," explains Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc. in Lansdale, Pa.

Get to Know 5 Levels of NOPP

The CPT manual defines NOPP as a "contributing" E/M component, but not one of the key elements. Discerning NOPP level is important, however, when choosing the level of medical decision making, explains Yvonne P. Bouvier, CPC, CEDC, senior coding analyst at Bill Dunbar and Associates in Indianapolis.

Here are the five levels of NOPP:

• Minimal NOPP might not require a physician's presence; but is provided under the physician's supervision.
• Minor or self-limited NOPP is not likely to alter the patient's health permanently; problems in this NOPP level run a proscribed course and then fade. Patients with minor or self-limited NOPP have an extremely low risk of morbidity without treatment.
• Moderate NOPP patients have a moderate risk of morbidity without treatment, or at least an increased probability of prolonged functional impairment.
• High NOPP patients have a high to extreme risk morbidity without medical attention; a high NOPP might also involve the possibility of severe functional impairment without treatment.

Check out this rule of thumb for NOPP decisions, from Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La.:

"What risk is there if the physician provided no treatment?" The answer to that question determines your NOPP, says Edelberg.

Minor or self-limited NOPP example: A patient presents to the ED with a cold, and the physician tells the patient to rest and gargle with salt water. In this scenario, you'd choose a low-level ED E/M code, such as 99281 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a problem focused history; a problem focused examination; and straightforward medical decision making ...) or 99282 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity ....), says Falbo.

Moderate NOPP example: A patient presents with complaints of uncontrollable belching, frequent vomiting and nausea for 36 hours. The physician administers a gastrointestinal (GI) cocktail and the pain abates. The ED physician then prescribes medication and instructs the patient to follow up with a gastroenterologist within two weeks.

The prescription drug management supports moderate MDM, which is a required component of both 99283 and 99284. The documentation would then have to include at least an expanded problem focused history and exam to support 99283.

To support 99284 you would need a detailed history and physical exam with an urgent NOPP, including some more severe symptoms or physician concerns as evidenced by diagnostic testing or a differential diagnosis.

Consider Comorbidities Before Choosing NOPP Level

You must consider the condition the patient presents with along with any comorbidities in order to arrive at the proper NOPP level, stresses Joan Gilhooly, PCS, CPC, CHCC, vice president, Audit Services and Compliance for Health Management Resources in Salisbury, N.C.

Example: A patient has an NOPP of mild hypertension with slight elevation, but also suffers from lupus, a comorbidity that sends the NOPP level up. In this example, "the NOPP will be much higher because of preexisting conditions and medical history," says Gilhooly.

High NOPP Does Not Always Mean 99285

Since there are five levels of NOPP, it might be tempting to assume each one coincides with an ED E/M code; minimal NOPP equals 99281, self-limited NOPP equals 99282, etc. This is a dangerous coding practice, however.

Reminder: Two out of three is bad when coding for ED E/Ms. There are three key components for each ED E/M level; therefore, the NOPP is a fourth contributory element. High NOPP does not necessarily mean that the physician provided level-five ED E/M service; the visit would also have to satisfy key elements of comprehensive history, comprehensive exam, and medical decision making of high complexity.

Use the NOPP to help you finalize your code choice , but you must also consider the history and examination components when choosing an ED E/M code.