ED Coding and Reimbursement Alert

Question: A 20 year-old patient presents to the ED with a fever of 105, weakness and body aches. He went to his regular physician yesterday who had prescribed an antibiotic. The documentation seems to only warrant a level two E/M code (99282), but I don't feel this is sufficient for the situation. The problem is the documentation shows a detailed history and detailed exam but the only treatment done in the ED is lab work. The physician gives no medication to the patient during the ED encounter, nor does he send him home with any. Should we report this case as a 99282 because of this low medical decision-making?

Tennessee Subscriber

Answer: This patient sounds like he has a higher nature of the presenting problem (NOPP) than is warranted by a 99282 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of low complexity).

Using the Marshfield Clinic audit tool, your physician's medical decision-making qualifies as "moderate"; consequently warranting the level three E/M code, 99283 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and medical decision making of moderate complexity), instead of the 99282 you've selected.

For the MDM you have:

• a moderate level for the number of diagnoses/management options with a new problem to the examiner, no additional work-up planned
• a moderate level for risk of complications with an acute illness with systemic symptoms.

You only need two components of the MDM to meet or exceed a required level in order to report it, so you have met that requirement for "moderate." You should note that if the physician told the patient to continue using the originally prescribed antibiotic, such documentation could constitute prescription management if well documented.

You also have a detailed history and exam, both of which exceed the level three E/M code requirements, but you must have all three of the E/M components meet or exceed a level to report that code. That means you can report a code higher than you originally thought. The code choice would be a least a level 3 since this scenario sounds like a nature of the presenting problem of moderate severity as stated in the CPT® descriptor for a 99283.

But you can take into account other factors besides these mentioned when determining your E/M level. Since the documentation requirement are met, you would next consider whether you should report this as a level four ED service, 99284 (Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: a detailed history; a detailed examination; and medical decision making of moderate complexity), based on lab work and the rest of the ED course and documentation.