Primary Care Coding Alert

Use this guide, understand how presenting problems relate to E/M levels.

Whenever you calculate an evaluation and management (E/M) level based on key components, you know that new patient E/Ms currently require all three elements — a history, an exam, and medical decision making (MDM) — to be present at different levels. You also know that established patient E/Ms only require two of the three elements to factor into your levelling calculations.

But what about the nature of presenting problem, or NOPP? CPT^® guidelines note that “the E/M codes recognize five types of presenting problems.” But what are they? And how do they factor into E/M level calculations? Read on and get all your presenting problem questions answered.

What is the NOPP and How Do You Use it?

“The NOPP is listed in the description of all E/M codes as an additional component that might influence the providers’ choice of the level of service applicable on the date of the encounter,” explains Melanie Witt, RN, CPC, MA, an independent coding expert based in Guadalupita, New Mexico.

“It is not a measurable tool during an E/M audit but rather offers additional insight into why a provider may have selected a particular code and whether that assumption was indeed supported by the history, exam, and medical decision making documented,” Witt elaborates.

In other words, “when I have determined the level of E/M based on history, exam, and/or decision making, depending on the type of service, I then use the presenting problem to do what I call the ‘smell’ test’ to audit the encounter,” says Jan Rasmussen, PCS, CPC, ACS-GI, ACS-OB, owner/consultant of Professional Coding Solutions in Holcombe, Wisconsin.

What Constitutes a Presenting Problem?

You can determine a patient’s presenting problem type using the following CPT^® guidelines. We’ve also added some typical examples from primary care taken from the clinical examples, provided in Appendix C of the CPT^® manual, to help you connect the definitions to encounters that may be familiar to you.

Minimal presenting problems might not require a physician’s presence but do require a service provided under the physician’s supervision.

• Example: “Office visit for an 82-year-old female, established patient, for a monthly B12 injection with documented vitamin B12 deficiency” (99211).

Minor or self-limited presenting problems run a definite, prescribed course then fade (i.e., they’re transient); they are not likely to alter the patient’s health permanently and have a good prognosis with management/compliance.

• Example: “Office visit for an 11-year-old, established patient, seen in follow-up for mild comedonal acne of the cheeks on topical desquamating agents” (99212).

Low severity presenting problems have a low risk of morbidity without treatment, there is little to no risk of mortality without treatment, and the patient is expected to recover fully without functional impairment.

• Example: “Office visit for a 62-year-old female, established patient, for follow-up for stable cirrhosis of the liver” (99213).

Moderate severity presenting problems have a moderate risk of morbidity, uncertain prognosis, or an increased probability of prolonged functional impairment without treatment. There is moderate risk
of mortality without treatment.

• Example: “Initial office visit for a 17-year-old female with depression” (99204).

High severity presenting problems have an extreme or high risk of morbidity without medical attention or face the probability of severe, prolonged functional impairment without treatment. There is a moderate to high risk of mortality without treatment.

• Example: “Office visit for evaluation of recent syncopal attacks in a 70-year-old female, established patient” (99215).

Coding caution: CPT^® guidelines stipulate that the presenting problem can be determined “with or without a diagnosis being established at the time of the encounter.”

How Does Knowing the NOPP Types Help Your Coding?

“Appendix C in the CPT^® manual is full of examples for all the levels of service, which approximate what to expect for different levels of the presenting problem. I would encourage any coder or biller who is responsible for checking provider documentation to be familiar with these examples and use them to assist providers who routinely perform/document higher levels of history or exam than would be warranted by the presenting problem,” advises Witt.

How Does NOPP Factor Into E/M Levels?

While NOPP on its own cannot help you determine an E/M level, you can “use the nature of the presenting problem to substantiate the need for a higher level of service,” according to Witt. “For instance, if the patient is presenting for an IUD check, you would not expect the provider to document a comprehensive history and detailed exam — especially if the IUD strings are found and the patient has no complaints. It is my ‘check’ on the reasonableness and medical need for the key elements documented in the medical record for that encounter,” says Witt.

The following chart shows how the presenting problems as defined by CPT^® align with the different E/M levels for new or established patients:

The table shows that if a new patient’s presenting problems are of moderately severity, you should be able to justify four of the five levels of new patient
E/Ms if all the key components of the E/M are satisfied. Conversely, an established patient’s presenting problems are more evenly distributed by severity over the E/M levels, enabling you to more precisely correlate the presenting problem with the E/M level when checking for medical necessity.

That’s why “it is important to understand the presenting problems to decide if the actual presenting problem and or additional chronic problems impacting the presenting problem support the level determined by the history/exam/decision making,” concludes Rasmussen.