ED Coding and Reimbursement Alert

Answer: First, if you use the Marshfield Clinic worksheet and auditing tool, your physician's medical decision-making (MDM) qualifies as "moderate," consequently warranting the level-three E/M code, 99283, 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 workup planned
 

 a moderate level for risk of complications with an acute illness with systemic symptoms
 
You only need two components of the three MDM to meet or exceed a level to report it, so you have met that requirement for "moderate." You also have a detailed history and exam, both of which exceed the level-three E/M requirements.
 
But you must have all three of the E/M components (history, physical and MDM) to meet or exceed a level to report it. That means you can report a level-three E/M code, higher than you originally thought, but not a level four. In fact, it is common convention to report 99283 because the nature of the presenting problem is of moderate severity as stated in the CPT descriptor for 99283.
 
But you can take into account other factors beside these mentioned when determining your E/M level. Remember, not all payers use the strict Medicare audit review sheet (which might suggest a level three in your case) to reimburse E/M services. Your department must decide whether you bump up this level-three service to a level four based on the legitimate consideration of the nature of the presenting problem.
 
You should remember that if the physician told the patient to continue using the originally prescribed antibiotic, that work could constitute management if it is well documented.