ED Coding and Reimbursement Alert

Here's why lining up presenting problem levels with 99281-99285 could spell trouble.

Failure to identify the nature of the presenting problem (NOPP) level for each patient can cost you, as this ED E/M element is essential to protecting your 99281-99285 claims.

Get smart with this NOPP FAQ, which will help lead you to the correct level each time.

What is NOPP?

NOPP is the "disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the visit to the ED -- with or without a diagnosis being established at the time of the encounter," explained Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, La., during a recent Coding Institute audioconference (www.audioeducator.com).

In a nutshell: Ask yourself, "What risk is there if the physician provided no treatment?" The answer to that question is your NOPP.

What Coding Component Does NOPP Factor Into?

You'll use NOPP information when deciding the level of service for ED E/M services (99281-99285, Emergency department visit for the evaluation and management of a patient, which requires these 3 key components ...),

confirms Linda Martien, CPC, CPC-H, coding specialist at National Healing Inc. in Boca Raton, Fla. "The presenting problem drives the processes and outcomes," she says.

NOPP information is vital to deciding the level of medical decision making involved in the encounter, says Yvonne P. Bouvier, CPC, CEDC, senior coding analyst at Bill Dunbar and Associates in Indianapolis. Without it, MDM levels are not clear, which can lead to miscoding. "It would not be appropriate to bill a higher level of E/M when a lower level is warranted," says Bouvier. Remember, history and physical exam documentation by itself does not determine the level of care you'll assign; the clinical course it supports is what determines the NOPP.

How Many NOPP Levels Are There?

There are five different NOPP levels, which are loosely connected to the five levels of ED E/M service (99281-99285). The NOPP levels are:

• Minimal: a problem that may not require the presence of a physician.

• Minor: also self-limited, the problem runs a definite and proscribed course, and is not likely to permanently alter future health status.

• Low: risk of morbidity without treatment is low or nonexistent.

• Moderate: risk of morbidity without treatment is moderate; there is a moderate risk of mortality without treatment, or increased probability of prolonged functional impairment.

• High: risk of morbidity without treatment is high to extreme; there is a moderate to high risk of mortality, or severe functional impairment, without treatment.

Example: An 8-year-old patient reports to the ED with a severe arm injury, and is ultimately diagnosed with a fractured radius. The physician splints the patient's arm, and arranges follow-up with an orthopedist to ensure proper healing.

In this instance, the NOPP was likely moderate. So on the claim, you would report 99283 (... an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity ... Usually, the presenting problem[s] are of moderate severity).

So If I Have High NOPP, Should I Code Level 4-5?

Not necessarily. These codes parallel the ED E/M codes "in name, but not in criteria or process," explains Martien. So if a patient has high NOPP, it does not automatically mean you can report 99285 (... 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 ... Usually, the presenting problem[s] are of high severity ...) -- or even 99284 (... a detailed history; a detailed examination; and medical decision making of moderate complexity ... 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).

Do this: You should always base your ultimate service level on the key components as specified by either the 1995 or 1997 E/M guidelines as well as consideration of the NOPP, Martien recommends.

Example: A 65-year-old male presents complaining of "6 out of 10" chest pain. The patient is awake and alert; an electrocardiogram (ECG) shows some non specific T-wave changes, and the physician relieves the patient's pain with nitroglycerin. The physician documents an expanded problem-focused history with only three history of present illness (HPI) elements and a comprehensive exam.

Although the NOPP in this case is high, the history documentation does not meet the requirements for a higher-level service. In this instance, the other components of the encounter compel you to report 99283 for the service.