In most EDs, the Level 3 and Level 4 evaluation and management (E/M) codes are the ones most commonly reported. However, the line between a Level 3 service and that of a Level 4 can sometimes be hard to distinguish.
The medical decision-making required for both codes is the same: moderate complexity. The technical difference between the two levels of service lies mainly in the level of history taken and the level of physical examination performed by the physician.
CPT® 99283 requires the performance of an expanded problem-focused history and physical while
CPT® 99284 requires a detailed history and physical.
However many coding and billing experts are warning that just because the physician documents a more extensive history and physical than is required for a 99283, the service provided does not merit reporting 99284.
I have done chart audits on Level 3 and Level 4 visits because the medical decision-making is the same, and I have seen some that I didn’t think used very good judgment, says
Jackie Davis president of Term Billing, an emergency medicine billing company in Austin, TX. For example I saw a lot of otitis media (infection of the middle ear) coded at a Level 4. No matter what the guidelines are you still have to use common sense and integrity. Treatment of otitis media is rarely going to warrant a Level 4, maybe with a complication such as bronchitis, but almost never just otitis media by itself.
Requirements of History
The first component of any of the emergency service E/M levels is the level of history taken.
According to the CPT® documentation guidelines both the 1995 and 1997 versions there are three components to a medical history: history of present illness (HPI) review of systems (ROS) and a past family or social history (PFSH) related to the presenting problem or problems.
For code 99283 only a history of present illness and a brief review of systems are required, advises Davis.
Up to a Level 3 you only have to have one element for the HPI and review of one system, she says.
However, to report a Level 4 you need at least a brief HPI, an extended ROS (2-9 elements) and at least one element of PFSH.
On Level 4 you have to have at least one of the three from either a past medical, family, or social history Davis explains.
Examination Requirements
The second component of the E/M level is the physical examination.
A 99283 requires an expanded problem-focused examination. According to 1995 documentation guidelines, this level of exam requires the documentation of the examination of the affected body area or organ system and at least one related body area or organ system (up to seven other areas/systems).
According to the 1997 guidelines, which instituted bulleted items on templates for each body area/organ system, the exam must include a general multisystem examination of at least six bulleted items documented or a single organ system examination with documentation of at least six bulleted items.
Medical Decision-Making
The third component of an ED E/M service is the level of medical decision-making (MDM) employed by the physician to establish a diagnosis and determine treatment.
CPT® documentation guidelines also establish three components of MDM: the number of diagnoses and management options considered, the amount and/or complexity of data reviewed by the provider, and the risk of morbidity or mortality to the patient.
As stated before, both a 99283 and 99284 require MDM of moderate complexity. In order to reach an overall level of moderate complexity, two of the three MDM components must meet or exceed a moderate level.
Although this is not strictly defined, many ED groups are using the Marshfield Clinic Scoresheet criteria for establishing the level of MDM which Medicare auditors often use. This method assigns numerical point values to items in each of the MDM components. (
For a detailed example of this scoring system see article on reporting 99282 in the September 1999 issue of ECA.)
The Marshfield Clinic’s format defines moderate complexity as multiple number of diagnoses or management options (a score of 3); moderate amount and/or complexity of data (a score of 3) and the highest risk to the patient defined as moderate.
When determining the level of risk, the Marshfield Clinic Scoresheet considers three more components: the risk of the presenting problems the risk of any diagnostic procedures ordered and the risk posed by the management options selected.
Level of Risk and Medical Necessity
Should Drive Code Choice
When considering all of the above requirements it has become apparent to some coders that if the physician always documents a detailed history including at least one element of PFSH and performs a detailed exam then they can report a 99284 instead of a 99283 according to the guidelines.
There are a lot of physicians out there who do a lot in the history and physical just to be thorough; they are not trying to abuse the system. But that doesn’t mean that they should always be reporting the higher level of service, advises
Pat Moore vice president of reimbursement for Healthcare Business Resources Inc. an emergency medicine billing company in Durham NC.
CPT® indicates that for code 99283 the presenting problems are usually of moderate severity while for code 99284 the presenting problems are usually of high severity.
Moore and Davis emphasize that coders and physicians must consider the level of service justified by the patient complaint when choosing an E/M level to report.
Some doctors just get in the habit of documenting extensively on everything, says Davis. It is the coder
’s job to then look in the CPT® book and understand the difference between a Level 3 and Level 4 service.
In fact, even if you base your code choice on MDM first and then calculate the level of history and physical, you could still wind up reporting a higher level of service than is really justifiable unless you are careful, Moore states.
Because assigning an MDM level requires only two of the three components to be a moderate level, then coders can base their overall MDM on the number of diagnoses and management options considered and the amount and/or complexity of data reviewed.
This can result in the coding of 99284 for patients with relatively minor problems such as otitis media.
I like to consider the risk of morbidity and mortality to the patient (when deciding between a Level 3 and a Level 4), Moore clarifies. If the patient presents and requires an urgent evaluation, then that is the patient that is a Level 4 patient. It’s not the patient that you leave the patient you are with and go to the new patient that is more of a Level 5. But it is a patient that needs to be seen urgently.
Exceptions
There are exceptions to her urgent examination rule, she notes.
Sometimes you have patients that don’t require an urgent evaluation but because of the nature of their illness they are going to need more tests or they are going to have a good deal of data to review or you have an increased number of management options starting IVs or interventions like that, Moore continues. It isn’t really that there is a high severity of illness. But that the risk is still high for these patients.
She notes a patient may present with a seemingly mild complaint but upon examination the physician finds more health problems that need to be evaluated at that visit because of the risk to the patient.
For example: Say you have an elderly patient who comes into the ED after a fall complaining of hip pain and you discover that they have uncontrolled hypertension, she says. 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. Adding the hypertension to the presentation can complicate the treatment. These additional problems can bring the visit up to a Level 4, Moore explains.
