ED Coding and Reimbursement Alert

Question: I was recently dinged in an internal audit for coding too low for things like ankle sprain and toothaches when the documentation had a comprehensive history, comprehensive exam and moderate MDM (due to a prescription being given). How much should the presenting problem calculate into assigning the appropriate level of service?

Oklahoma Subscriber

Answer: The problem you mention is becoming more common. Physicians are documenting better now than ever before. As a result, selecting an ED E/M code is not as straightforward as an audit sheet makes it out to be.

It is increasingly more important for an ED coder to be able to accurately assign E/M codes that are consistent with the level of care that was medically necessary to evaluate the patient.

CPT^® addresses medical necessity by assigning a nature of presenting problem (NOPP) when describing the levels of service. In CPT^® each of the ED E&M codes is associated with a nature of presenting problem.

99281 -- Usually, the presenting problem(s) are self- limited or minor.

99282 -- Usually, the presenting problem(s) are of low to moderate severity.

99283 -- Usually, the presenting problem(s) are of moderate severity.

99284 -- Usually, the presenting problem(s) are of high severity, and require urgent evaluation by the physician but do not pose an immediate significant threat to life or physiologic function.

99285 -- Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life of physiologic function.

CMS has addressed the issue of medical necessity in Medicare Carriers Manual. "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.

There will be many times in a coder’s daily workflow where the documentation in a chart may support a 99284 or 99285 E&M code but the nature of presenting problem and medical necessity indicate that a lower code is more appropriate.