ED Coding and Reimbursement Alert

Hone your coding skills with these 3 scenarios Choosing between two neighboring E/M levels can be tricky, especially when medications or pediatric patients are involved. Provide your answer to these E/M coding questions to see whether you can sort out level-three and level-four services. Consider Drugs for MDM Scenario 1: A 4-month-old who has had a cough and congestion for two weeks presents in the emergency department (ED) with a low-grade fever but no other problems. The physician considers several diagnostic options: respiratory infection (ruling out pneumonia), flu, and respiratory syncytial virus. He orders a chest x-ray (which is clear) and rapid flu test (AB negative). He then discharges the patient with a prescription for medication and a final diagnosis of respiratory infection. Should you report 99283 or 99284?

Answer: Assuming all the documentation is there, you should report 99284 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: a detailed history, a detailed examination, and medical decision-making of moderate complexity), says Nettie McFarland, RHIT, CCS-P, coding manager at DuvaSawko in Daytona Beach, Fla.
The x-ray interpretation (whether or not your practice bills for it separately) and the prescription medication administration indicate that the medical decision-making (MDM) was of moderate complexity, which leaves you to choose between 99283     (... an expanded problem-focused history, an expanded problem-focused examination, and medical decision-making of moderate complexity) and 99284.
 
Remember that according to CPT guidelines, there are actually seven components used in defining the level of evaluation and management service, says Michael A. Granovsky MD, CPC, FACEP, vice president of Medical Reimbursement Systems Inc. in Stoneham, Mass. These include history, examination, medical decision-making, counseling, coordination of care, nature of the presenting problem, and time.

In this case, because the patient is a 4-month-old baby, certain aspects of the care - such as the nature of the presenting problem - go beyond just documentation and medical decision-making.

Warning: While the doctor's x-ray order and medication prescribing place the MDM in the "moderate" category, you shouldn't automatically translate that to mean the E/M service warrants a level four instead of a level three. The history and exam elements need to match 99284 requirements, and the nature of the presenting problem should fit with a level four. Weigh NOPP for Encounter Level Scenario 2: A 17-year-old male presents in the ED after smashing his finger in a drawer two hours ago. He complains that the finger is throbbing, and he has pain bending it. He has no numbness or tingling. He has current immunizations and no known drug allergies.

Vital signs are stable; oriented times three. He has full range of motion in his other fingers. There is a slight abrasion proximal [...]