ED Coding and Reimbursement Alert

Question: A mother reports to the ED with her 6-day-old son after a moderate motor vehicle accident. The mother wants the physician to check her son to make sure he has no injuries. The physician performs an expanded problem-focused history and, in an effort to screen for injuries, a very thorough detailed exam. During the evaluation, she runs no test and prescribes no drugs for treatment. However, the physician does counsel the patient's mother regarding a follow-up exam. What level of evaluation and management service should I report for this scenario?

Oregon Subscriber

Answer: You should check the notes again before deciding on a level, just to make sure all the details of the encounter are reflected in the medical record.
 
Remember that per CPT, there are seven determinants of the E/M level. The history, physical exam, and MDM are the key elements. The next element to consider in a case like this is the nature of the presenting problem. The medical decision-making in this case would be based on the possibility of a multiple number of diagnosis or management options, with no data, and moderate risk or complications.
 
Clinically the nature of the presenting problem (a 6-day-old in an MVA) is moderate. Ultimately, a level-three  E/M service typically represents these cases.
 
On your claim:
 - report 99283 (Emergency department visit for the evaluation and management of a patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and medical decision-making of moderate complexity) for the E/M.
 - link V71.4 (Observation following other accident) to 99283 to indicate the reason for the E/M.
 - link ICD-9 code E812.1 (Other motor vehicle traffic accident involving collision with a motor vehicle; passenger in motor vehicle other than motorcycle) to 99283 to represent the cause of the patient's accident.