Primary Care Coding Alert

Read our scenario and decide which way you'd code.

Just because you code for your physician's E/M services every day doesn't mean they're always simple to resolve. Check out this real-life scenario and decide how you would code it, then turn to page 29 for our experts' advice.

The family physician sees an established patient for a new problem. The documentation reads, "Diagnosis: abdominal pain. Patient does not want work up today. Suspect ovarian cyst. If pain persists tomorrow, she will call and plan pelvic u/s or CT depending on sx at that time. Patient agrees, does not want pain pills. She will take ibuprofen."

How would you code this encounter?

Answer: "This situation represents moderate medical decision-making," says Dawn Silva, CPC, CCP, compliance officer with Marin Medical Practice Concepts in Novato, Cal. "You have an undiagnosed, new problem with an uncertain prognosis."

"At first glance, you might think this is just a minor problem since the provider didn't push for testing and was fine with the patient going home to take over-the-counter ibuprofen," adds Linda Vargas, CPC, CEMC, coding and reimbursement specialist at Cass Regional Medical Center in Harrisonville, Mo. "But since there was no definitive diagnosis, and the possibility of testing, you should consider this a 'new' problem even without a work up."

A new problem with no diagnosis supports moderate complexity medical decision making both in terms of the diagnosis and management options and in terms of the risk involved. Since the level of medical decision making involved depends on meeting two of the three medical decision making elements (i.e. diagnosis and management options; amount and complexity of data reviewed; and risk), this documentation appears to support a moderate level, even though the amount and complexity of data reviewed is minimal or none.

Code check: E/M code 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; medical decision making of moderate complexity) notes "medical decision making of moderate complexity," but that shouldn't be your automatic code choice. If this case were on your desk, you would need to verify that the physician also reached the level of "detailed" history or exam before you could submit 99214.

If you can't support a detailed history or exam to go with the moderate level of decision-making, you'll need to drop back to 99212 (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 problem focused history; a problem focused examination; straightforward medical decision making). Based on the documentation, you can infer at least a problem-focused history. Include diagnosis 789.0x (Abdominal pain). If other notes in the physician's documentation specify which abdominal quadrant has pain, use that information to select the fifth digit (such as 3, Abdominal pain, lower right quadrant). If the physician doesn't specify a quadrant, report 789.00 (Abdominal pain, unspecified site).