EM Coding Alert

Question: An established 22-year-old male patient was seen and our physician documented the following: “Patient complaining of a sprained right ankle and having difficulty applying pressure; hurts when walking. The patient was playing soccer that morning when the injury occurred. The patient is an avid soccer player and has sprained this ankle several times in the past.” The physician also reviewed the complete 14 systems that the nurse documented for review of systems and the past medical, family, and social history in the chart. The physician’s exam included checking the patient’s vital signs, noting that the ankle area was swollen, discolored, and warm to the touch, and determining that patient could bend the ankle with some discomfort and could walk with difficulty. The doctor ordered an x-ray, which showed no break, and prescribed an anti-inflammatory medication. How should I code this when our practice uses 1995 guidelines?

New York Subscriber

Answer: You could consider reporting 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a detailed history; a detailed examination; or medical decision making of moderate complexity ...) or 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: an expanded problem focused history; an expanded problem focused examination; and straightforward medical decision making...) for this encounter.

Scoring the service: Your provider documented a brief history of present illness (HPI) with four elements — location:  right ankle, severity: hurting, duration: four hours, and context: since playing soccer that morning. If the entire review of systems (ROS) was documented and there is proof that the doctor reviewed it, credit for a complete ROS can be given. The same applies to the past, family, and social history (PFSH). That would equate to an expanded problem focused history. 

For the exam, your provider reviewed three systems — Constitutional: vitals, Musculoskeletal: ankle bend, walking observation, and Integumentary: discolored and warm to the touch. Per 1995 guidelines, this is an expanded problem focused exam. 

For the medical decision making (MDM) you’ll count as follows — Diagnosis: new problem equals 3 points, Data: none (if x-ray was billed separately), and Level of risk: moderate for the acute injury, with systemic issues and prescription drug management. This leads to moderate complexity MDM.

Because established patient visits require that you satisfy just two out of three key elements, the comprehensive history and moderate complexity MDM support billing 99214.