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 to the active nail, but no bleeding. The patient has sensation to a needle prick. The doctor gives him a prescription for 600 mg of ibuprofen for pain, and discharges him with a final diagnosis of finger contusion. Should you report 99283 or 99284?

Answer: If you account for the detailed history, detailed examination, and moderate MDM, this documentation clearly supports billing 99284 - but don't write it down just yet. Instead, take a look at the nature of the presenting problem (NOPP), and you'll come up with the correct answer: 99283.

Regardless of the documentation in the emergency chart, you must consider the medical necessity of the encounter when selecting the E/M level. Because physicians are educated on documentation requirements, and more EDs are using templates or prompted dictation systems, you're more likely than ever before to get more details about patient encounters. But don't be fooled into reporting a higher E/M level just because you have more documentation at your disposal.

CPT provides guidance on how to determine the right level of service for a given NOPP by recognizing four types of presenting problems. These are the three you'll usually see in the ED:

  Low severity: A problem in which the risk of morbidity without treatment is low; there is little to no risk of mortality without treatment; full recovery without functional impairment is expected.

  Moderate severity: A problem in which the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.

  High severity: A problem in which the risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality without treatment OR high probability of severe, prolonged functional impairment.

The code descriptor for 99283 indicates a presenting problem of moderate severity, while the descriptor for 99284 indicates high severity. Code 99283 is therefore more appropriate for this episode of care.

Talk to Physician Before Caveat

Scenario 3: A 14-month-old patient with a high fever presents to the ED. The physician's documentation includes a chief complaint, six elements of the history of present illness, past family and social history, and a complete physical examination.

The physician draws blood for lab tests, orders a chest x-ray and performs a lumbar puncture. She diagnoses the child with bacterial meningitis and admits him.

The review of systems (ROS) documentation only shows seven systems, broken down as follows:

Constitutional: Positive for fever/chills, decreased fluid intake.

ENT: Positive for nasal discharge.

Resp: Positive for cough, upper respiratory congestion. No breathing difficulty.

Gastro: No diarrhea, not vomiting.

Genit: No blood in urine.

Neurological: No loss of consciousness.

Integ: No diaphoresis, no rash.

Which E/M code should you report?

Answer: This situation is unique because all of the ROS information comes from the parents/caregivers. They may be able to offer just as much history on the child's behalf as an adult patient would be able to give. But if the parents are unable to give enough history, then the physician should note that.

If the child is too sick for the provider to take more history, then you should invoke the acuity caveat and report 99285 (Emergency department visit for the evaluation and management of a patient, which requires these three key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: a comprehensive history, a comprehensive examination, and medical decision-making of high complexity).
 
Tip: Consider giving the physician the opportunity to clarify things further before you invoke the caveat or determine that no further history is available. You might want a better understanding of the possible limitations that came into play in order to choose the most appropriate code for this case.