Inpatient Facility Coding & Compliance Alert

Question:  A patient with a chronic gastric ulcer reports to the ED complaining of nausea, vomiting, and headache. One of our nurse practitioners spends 34 minutes with the patient, and performs an expanded problem focused history, problem focused examination with moderate-complexity medical decision making during the encounter. 

During the history portion of the E/M, the patient reveals that she has not been to a physician in several years for treatment of her ulcer. The note indicates that the NP spent 21 minutes advising the patient on proper diet and medication management, and encouraging the patient to resume regular physician visits for management of her condition. Is this an instance where I can code based on total encounter time for the counseling?

New Jersey Subscriber 

Answer: 

The E/M guidelines do allow an option for reporting time counseling and coordination of care based on the typical times associated with appropriate code descriptor such as office based codes. However, the ED E/M codes are not based on time, so you have to choose an E/M code based on the level of service regardless of how much time the provider spends counseling the patient. On the claim, report the following

• 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 ...) for the E/M
• .01 (Nausea with vomiting) appended to 99283 to represent the patient’s nausea and vomiting
• 784.0 (Headache) appended to 99283 to represent the patient’s headache
• 531.70 (Chronic gastric ulcer; without hemorrhage or perforation, without obstruction) appended to 99283 to represent the patient’s ulcer.

Looking ahead: Here’s how you’ll report the diagnoses when ICD-10 becomes effective (now scheduled for October 2015):

• R11.2 (Nausea with vomiting, unspecified) 
• R51 (Headache) 
• K25.7 (Chronic gastric ulcer without hemorrhage or perforation).