ED Coding and Reimbursement Alert

It’s not just about counting bullets anymore.

If you’re like most ED coders, determining exactly when you should report a level 3 or  level 4 evaluation and management (E/M) codes requires some real sleuthing: Unless you can identify certain distinguishing details, your E/M coding could be error-ridden. Read on for advice on how to tame the level 3/level 4 beast.

The challenge: Identifying the difference between a 99283 and a 99284 can be difficult, even for an experienced coder, because  of the “urgency of presentation” statement as defined in the nature of the presenting problem (NOPP) language can be the primary discerning factor, says Stacie Norris, MBA, CPC, CCS-P, Director of Coding Quality Assurance of Zotec Partners in Durham, NC. 

The CPT® code descriptor for 99283: “Usually the presenting problem(s) are of moderate severity,” but the code descriptor for 99284 reads, “Usually the presenting problem(s) are of high severity and require urgent evaluation by the physician or other qualified healthcare professional, but do not pose an immediate threat to life or physiologic function.” 

Proof is in the H&P: The medical decision-making required for both codes is the same at 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. A level 3 code (99283) requires the performance of an expanded problem-focused history and physical while a level 4 code (99284) requires a detailed history and physical, says Norris.

Caveat: However, 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, Norris warns.

Don’t Go Overboard for Non-severe Complaints

In deciding between level 3 and level 4 visits the coder must use very good judgment, says Norris. For example most presentations of otitis media (infection of the middle ear) should not be coded at a level 4. No matter what the documentation guidelines are for history and physical exam, you still have to use common sense and integrity. Treatment of otitis media is rarely going to warrant a level 4 unless it is paired with a complication such as bronchitis. 

Another common example of cases that straddle the fence between a level 3 and a level 4 are cases where a patient has URI symptoms such as a sore throat, runny nose and a cough. Consider a patient who has only had these symptoms for two days; the symptoms are mild in nature with no fever. This is a case of moderate risk with low urgency of presentation and would appropriately be coded as a level 3 ED visit, Norris advises. 

However, if the patient has had the above symptoms for a week, plus a fever of 103, moderate cough with yellow sputum and malaise, this case exhibits some urgency and the ED provider will most likely order additional testing to rule-out a more severe problem such as bronchitis or pneumonia, and then a level 4 ED visit level is supported, Norris explains.

Review Doc Rules for 3 Key Components To Start the Decision of Level Assignment

1. History

The first key component of any of the emergency service E/M levels is the level of history taken.

According to the CPT® documentation guidelines for 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 brief history of present illness and a problem pertinent review of systems are required. However, to report a level 4, you need at least a brief HPI (with 4 or more elements of the HPI documented), an extended ROS (2-9 elements) and at least one element of PFSH.

To report a level 4, you have to have at least one of the three from either a past medical, family, or social history, Norris explains.

2. Examination

The second key 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 a limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (from two to four  other areas/systems). 

A 99284 requires a detailed physical examination, which is defined as an extended examination of the affected body area(s) and other symptomatic or related organ system. 

Critical: The numerical interpretation of problem-focused and detailed physical examination requirements of 2-4/5-7 is not mentioned in the 1995 documentation guidelines. This interpretation came from a Medicare medical officer in the mid 90’s and has been adopted by many carriers/payers, but you should always check with your individual payers to make certain they agree with this interpretation, Norris advises.

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.

Lately, some Medicare Area Contractors, have their own rules for required documentation for level 4, so be sure you are up to date with local rules, warns Norris.

3. Medical Decision-Making

The third key component of an ED E/M service is the level of medical decision-making (MDM) used 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.

Since both a 99283 and 99284 require MDM of moderate complexity, 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 is often used by Medicare auditors, notes Norris. This method assigns numerical point values to items in each of the MDM components, she says. 

The Marshfield Clinic format defines moderate complexity as a multiple number of diagnoses or management options (a score of 3); a 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, Norris explains. 

What Drives Code Choice? Level of Risk and Medical Necessity

When considering all of the above requirements, some ED coders think that if the physician always documents a detailed history, including at least one element of PFSH, and performs a detailed exam, then they can always report a 99284 instead of a 99283 according to the documentation guidelines, Norris explains.

With the wide use of EMR’s, many providers do document an extensive history and physical examination on almost every patient encounter, so this should not be the ultimate decision point for the visit level, warns Norris. 

CMS clearly states that “medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.” The level of MDM must be supported for the level of service billed, Norris adds. 

Your role: Some doctors just get in the habit of documenting extensively on everything, says Norris. 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, Norris states.

Because assigning an MDM level requires only two of the three listed 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, Norris says. 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),” says Norris. “If the patient presents and requires an urgent evaluation, then that patient is a level 4 patient. The presentations with a more urgent severity meet the NOPP language in the CPT® book,” she adds.

Be Aware of Exam Exceptions

There are exceptions to this urgent examination rule, says Norris. You may have patients that don’t require as urgent an evaluation, but because of the nature of their presenting illness, they are going to need more diagnostic tests or data to review, or you have an increased number of management options such as starting IVs more advanced interventions, she adds.

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, if a female patient presents with vaginal discharge and no other symptoms reported at triage, but upon examination the patient does exhibit some abdominal tenderness and also mentions she has had some painful urination. Even though the patient did not have a particularly urgent presentation, now she has several potential more serious rule-out diagnoses and the ED provider will likely order several diagnostic tests and a pelvic examination. A level 4 risk is supported in this case, says Norris.